Can criminalising deliberate HIV infections curb the HIV transmission rate, and so be good for public health? Or would such legislation negatively impact on voluntary counselling and testing (VCT), and therefore be bad for public health? With many countries in east and southern Africa either enacting or amending legislation to criminalise deliberate HIV infections, there has been mixed response to these questions and mixed reaction to such law reform.
Kenya, Tanzania and Uganda are currently introducing or amending laws to criminalise wilful HIV transmission as they view such laws as an effective tool to curb behaviour that carries the risk of HIV transmission and a legal contribution to the supportive environment for behavior change. These laws generally provide for sanctions when an individual who knows their HIV status knowingly and wilfully infects another individual with HIV. They are proposed as a measure to protect people with less power. By providing sanctions against wilful transmission of HIV, such laws are argued to protect the more vulnerable groups, usually women and young girls, in their sexual relations with those who are more powerful - usually men and wealthy people. They intend to reduce the impunity with which the powerful coerce others into sex, through acts such as rape and defilement, or into practicing unsafe sex (for example through commercial sex work), and so act as a deterrent against these practices.
However, a range of stakeholders involved in HIV related work, from legal, health rights and public health backgrounds, argue that ordinary criminal law provides sufficient legal mechanisms to hold someone accountable for wanton and deliberate infection of sexual partners. A special law to mandate criminalisation of HIV transmission could be bad for public health, harming initiatives such as voluntary counseling and testing (VCT) by deterring individuals engaged in high-risk or criminal sexual behavior from finding out their HIV status, in order to avoid prosecution under this law. Knowledge of HIV status is an entry point to many public health interventions to both prevent HIV and manage AIDS. With women commonly tested for HIV status through antenatal programmes, such laws may increase women’s vulnerability. Laws criminalising deliberate HIV infections could increase stigma, and violate the rights of persons living with HIV to life, health, treatment and freedom from cruel, inhuman or degrading treatment if effective care is lacking, or discontinued, through imprisonment. Emmanuel Mziray, GIPA Adviser to UNAIDS in Tanzania, observes that: ‘prohibiting alcohol and other drugs, consensual sex, or prostitution has never succeeded in preventing these behaviors’.
Criminalising deliberate HIV infections also raises a number of issues relevant to application of the law. It raises questions, for example, about the whether people living with HIV have a legal duty to disclose their HIV status before engaging in sexual activities that can lead to transmission of the virus? If so, then how do you prove in court that the person breached this legal duty? Further there are difficulties in proving the link between the sexual activity and the HIV transmission.
In a bid to address these concerns, USAID recently produced a policy options paper (See: http://data.unaids.org/Publications/IRC-pub02/JC733CriminalLaw_en.pdf) proposing some principles to guide thinking about, and development of, law and policy on the question of criminal law and HIV/AIDS. The paper identifies a number of public policy considerations that countries should consider when making decisions about using criminal law to tackle deliberate HIV infections. It warns that government officials and the judiciary involved in the development and implementation of such policies should be knowledgeable of the best available scientific evidence regarding modes of HIV transmission. Risk levels should form the basis for rationally determining if, and when, conduct should attract criminal liability. This is very challenging in settings where the judiciary may not be familiar with latest scientific evidence regarding on HIV transmission, particularly where there may be debate about levels of risk.
USAID propose that any legal or policy responses to HIV, particularly through the coercive use of state power, should not only be pragmatic in the overall pursuit of public health, but should also conform to international human rights norms, particularly the principles of non-discrimination and due process. State action which infringes on human rights must be adequately justified and policy-makers should always assess the impact of law or policy on human rights, choosing the ‘least intrusive’ measures possible to achieve the demonstrably justified objective of preventing disease transmission. As pointed out by Shanaaz Mathews in the April 2006 edition of the South African Medical Journal, international guidelines on HIV and human rights developed by UNAIDS and the Office of the United Nations High Commissioner for Human Rights (OHCHR) point out that criminal or public health legislation should not include specific offences against deliberate transmission of HIV, but that the latter should be tried under general criminal law, a position endorsed by the South African Law Commission (SALC) in 2001.
The development of such laws in Kenya, Uganda and Tanzania, amongst other ESA countries, suggest that these guidelines are not being followed. In Tanzania the proposed law is under debate, and article 47 of the HIV and AIDS (Prevention and Control) Bill, 2007 provides: ‘Any person who willfully and intentionally transmits HIV to another person commits an offence, and on conviction shall be liable to life imprisonment’. In Kenya, section 26 of the Sexual Offences Act, 2006 makes it an offence for any person who with actual knowledge that he or she is infected with HIV or any other life threatening sexually transmitted disease intentionally, knowingly and willfully infects another person. Though Uganda has not enacted specific legislation criminalising deliberate HIV infections, it has amended its Penal Code Act to create the offence of aggravated defilement and aggravated rape where the offender was infected with HIV.
These laws do not appear to have addressed the human rights or public health concerns raised above, and assign the matter to courts who may have weak expertise in assessing the public health evidence. More generally, the public health impact of these measures are not monitored, neither the costs nor the potential benefits raised above. It is thus difficult to argue that they have been adequately justified, or that they are the ‘least intrusive’ measures possible to achieve their intention. The argument that the issue should be tried under general criminal law perhaps provides a legal remedy for clear violations of rights, without the negative consequences of a specific provision.
Policy and legal reforms are important in tackling the HIV epidemic. If human rights and public health issues are to be respected then it is vital that professionals and activists working on AIDS and people living with HIV be involved in and debate the legal reform processes in this area.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. Further information on health rights and AIDS can be found on the EQUINET website at www.equinetafrica.org
1. Editorial
2. Latest Equinet Updates
The Kamwenge Community Empowerment and Participation in Maternal Health Project aimed to contribute to the improvement of the health of expectant mothers in Kamwenge Sub-county, Kamwenge District. We aimed, through the use of PRA approaches, to increase demand for, access to and utilisation of maternal health services by expectant mothers. Using various PRA tools the project team worked with the community to prioritise, act and follow up on the most critical barriers to maternal health at the three levels – health service, community and household. While a comparison of questionnaires before and after the intervention suggested that maternal health problems remained high and many barriers to access services persisted, positive change was perceived in ease of access to and affordability of services, in communication between community and health workers and the respect shown by health workers, in the support given by health workers and families, and in awareness and action on maternal health in the community. The strongest positive changes were noted in the communication between health workers and pregnant women, and this seemed to be the area of greatest impact of the intervention.
This participatory action research project aimed to explore and strengthen the community’s capacity to recognise and advocate for their mental health needs, to increase the awareness of mental health problems among the community and to increase collaboration between the mental health workers from clinic and hospital level and the community in the management of mental health problems in the community. Both health workers and community identified exclusion, isolation and poor control over life, associated with risks and a poor physical state, as features of mental ill health. The Kariobangi community was felt to experience high levels of mental ill health, with poverty a major contributing factor. The major mental disorders identified were depression, stress, poverty, lack of awareness, drugs/substance abuse, lack of essential services (mental health services), mental retardation and epilepsy. The intervention is still at an early stage, but the evidence suggests that the PRA approach has strengthened community roles and interaction with health workers in improving mental health care in an underserved community.
Participatory approaches were used to facilitate a programme of work aimed at: improving communication and understanding between HIV positive clients and the HIV clinic personnel in HIV clinics; raising HIV positive clients’ voices and participation in improving the HIV clinic services in the division; and promoting networking to overcome isolation, increasing exchange and co-operation through conducting. Participatory approaches, while challenging and time intensive, were perceived by health workers, clients and the facilitators to be a powerful means to enhancing communication, overcoming power imbalances that are barriers to good health or effective use of services and to encouraging the sustainable, “bottom up” community involvement on health visioned in Kenya health policy documents. Real changes were made to make the services more client-friendly, including installed suggestion box, re-streamlined queuing and filling system, taking of vital signs, interpreter involvement, and ordering of bulk drug supply, while clients formed a network that would sustain the communication and reduce social isolation of PLWHIV.
Reviewing experience in selected countries in the region, this policy brief suggests that countries can strengthen equitable allocation of resources for health by increasing the overall share of government funding allocated to the health sector, bringing external aid and government funding into one pooled fund and allocating it through a single mechanism. Equitable resource allocation calls for governments to establish annual targets for equitable allocation of these public funds, and to collect information to monitor and report on progress in meeting these targets, including to parliaments and civil society. Resource allocation is a politicised process and requires careful management, including to plan, organise and provide incentives for redistributing health care staff to areas where health need is higher.
3. Equity in Health
The State of the World's Children 2008 provides a wide-ranging assessment of the current state of child survival and primary health care for mothers, newborns and children. The report argues that these issues serve as sensitive barometers of a country's development and wellbeing and as evidence of its priorities and values, and states that investing in the health of children and their mothers is a human rights imperative and one of the surest ways for a country to set its course towards a better future. The report identifies six pivotal actions at the macro level that urgently require unified engagement to intensify efforts for maternal, newborn and child survival and fulfil the right of women and children to health and well-being.
The Knowledge Networks of the Commission in different regions have completed their reports. These reports will inform the Commission's interim statement to be published later this year for broader consultation. They are available on the Commission website and cover areas of Early childhood development; Globalisation; Health Systems; Employment; Women and Gender equity; Urban Settings and Measurement and Evidence.
4. Values, Policies and Rights
The chief of malaria for the World Health Organization has complained that the growing dominance of malaria research by the Bill and Melinda Gates Foundation risks stifling a diversity of views among scientists and wiping out the world health agency’s policy-making function. In a memorandum, the malaria chief, Dr. Arata Kochi, complained to his boss, Dr. Margaret Chan, the director general of the W.H.O., that the foundation’s money, while crucial, could have “far-reaching, largely unintended consequences.”
Can court enforced health rights improve health policy and priority setting in poor countries? This multidisciplinary project aims to systematically investigate whether litigation can make health policies and -systems in poor countries more equitable by forcing policy-makers and administrators to take seriously their human rights obligations. Most of the world's governments are obliged through international treaties or national constitutions, or both, to respect, protect, promote and fulfill the human right to health. In most cases, this has not been an enforceable legal right. However, cases regarding the right to health care are increasingly brought before the courts. In a number of low- and middle-income countries - first in Latin America, later in Africa and Asia, court decisions have granted access to certain forms of medical treatment. These are decisions with potentially great implications for how health sector resources are prioritised and allocated, but so far there is little systematic knowledge of the actual effect of such cases on health policy formation, implementation and spending. Do they have a significant effect in practice? And, if so, do they contribute to more - or less - justice in health service delivery?
A workshop was held in July 2007 hosted by MOSAIC at which the participating South African organisations reviewed goals set by UNGASs on reproductive health rights, discussed identified indicators, refined these and shared research and findings. In South Africa in 2007 Government in collaboration with many stakeholders (civil society, the private sector) launched the HIV and AIDS and STI National Strategic Plan 2007 – 2011. While there is substantive discussion noting key areas of gender and gender based violence, cultural attitudes and practices, sexual concurrency and sex workers, there is no overall conceptual lens unpacking sexual and reproductive health and rights. Currently reproductive health is not on the essential health priority list. This leaves gaps in terms of the continuum of care and there is a lack of integration, for example, HIV positive women’s sexual and reproductive intentions are not provided for, abortion services are not regulated
within HIV care, sexual violence is not part of the STI syndromic approach.
5. Health equity in economic and trade policies
Given India's victory against Novartis in the drug company's challenge to section 3d of the India Patent Act and given Thailand's highly publicised campaign to issue compulsory licenses on both AIDS and heart disease medicines, we are now seeing a new wave of patent withdrawals and a growing wave of compulsory licenses. This reciprocal wave action creates a wider opening for continuing access to newer and lower costs medicines. But the promise of this opening will only be realized if more countries amend their patent acts to take advantage of the TRIPS-compliant, definitional flexibilities that India has enacted and if more countries use the TRIPS compliant flexibilities for issuing compulsory licenses for generic medicines that Thailand has used.
The Executive Council of the African Union was reported in January to have resolved that no African region should be allowed to sign the Economic Partnership Agreements (EPAs) with the European Union "as long as the draft agreement is not submitted and discussed at the continental level". The council believed that the signing of any interim or complete EPAs will affect other regions in Africa, recommended "the need for a political intervention at the highest level to protect the interest of African countries."
A brief look at each of the six negotiation regions gives a more detailed picture of the current state of play on the EPA negotiations. While all parties remain committed to concluding comprehensive EPAs, as confirmed in the joint review endorsed in May 2007, progress in the negotiations has been slower than expected. By October 2007, it became apparent that EPAs would not be concluded by the target date of 31 December 2007, set by the expiry of the WTO waiver covering the current preferential trade regime of Cotonou. In reaction to this, the European Commission issued a communication on 23 October 2007, which outlines a pragmatic approach to safeguard preferential market access for non-LDC countries from 1 January 20081. The communication aims at concluding WTO-compatible goods market access arrangements to be in order to extend the negotiation time towards complete EPAs while avoiding adisruption in trade. In line with this approach, a number of interim agreements were concluded over the last weeks of 2007 between the EU and ACP regions, subregions and individual countries. Trade in goods is the only key area that needs to be covered by an agreement to comply with WTO rules. Other areas, on which agreement has been found, are included in most interim agreements. The interim agreements contain rendezvous clauses to continue negotiations in 2008 towards full EPAs. A brief look in this report at each of the six negotiation regions gives a more detailed picture of the current state of play on the EPA negotiations.
Policymakers from the EU and developing countries, together with non governmental organisations and academics, met from 21-24 January at Wilton Park for a strategic and creative dialogue on the effectiveness of European development policy. With input from the Department for International Development and the European Centre for Development Policy Management, the group discussed Europe's development agenda and potential reforms. The group considered ways to improve aid effectiveness in preparation for the Paris commitment review meeting in Accra in September: the closing session was led by the Ghanaian Finance Minister.
6. Poverty and health
This paper describes changes over the past 15-20 years in non-income measures of wellbeing—education and health—in Africa. Results indicate that in the area of health, little progress is being made in terms of reducing pre-school age stunting, a clear manifestation of poor overall health. Likewise, our health inequality measure showed that while there were a few instances of reduced inequality along this dimension, there was, on balance, little evidence of success in improving equality of outcomes. Similar results were found in our examination of underweight women as an indicator of general current health status of adults. The overall picture gives little cause for complacency or optimism that Africa has reaped, or will soon reap the potential benefits of the process of globalisation.
From the vantage point of a rural district in northern Mozambique, the development efforts by government and donors are visible through the enhanced capacity of the local administration and investments in education and health, but not where it really matters for poor people: employment creation and reasonable returns from their agricultural production, which currently are adversely affected by an absent or exploitative private sector. The very poorest are marginalised or excluded from social relationships with the extended family, traditional institutions as well as the state, underlining the need to give special attention to the chronically poor and destitute in rural areas.
Issues of urban poverty have received little attention in Mozambique, even though the urban poverty rate is high and urban inequality is on the rise. In the bairros of Maputo, unemployment, crime and the high costs of food, housing and land inhibit the poor from converting progress in education and health into increased income and consumption. In a context where money is an integral part of most social relationships, the most destitute become marginalised with no one to turn to. Rising poverty and inequality in Maputo also have an adverse impact on vital urban-rural relationships, and may jeopardise political stability.
7. Equitable health services
Health Minister Manto Tshabalala-Msimang has called on the continent's health industry to improve access to affordable medicine. Access to healthcare is a constitutional right for all citizens of this continent.
All waste generated at health care facilities in the past was regarded as hazardous and was incinerated before disposal. Today however, waste generated at health facilities is separated out and disposed of according to the risks it poses. The purpose of this study was to investigate health care waste (HCW) management practices used in public health clinics in the iLembe Health District, with a view to developing a HCW management intervention strategy. The management of health care waste is of great concern. There is need to develop a health care waste management intervention strategy to be implemented consistently and universally in the district.
In line with international developments in mental health legislation, the Mental Health Care Act (2002) was promulgated in South Africa. Its core principles – human rights for users; decentralisation and integration of mental health care at primary, secondary and tertiary levels of care; and a focus on care, treatment and rehabilitation – are progressive and laudable. However, the task of implementing the requirements of the Act at community and district hospital levels is fraught with problems. Lack of infrastructure, inadequate skills and poor support and training undermine its successful implementation. Health workers already burdened with enormous workloads and inadequate resources struggle to manage mentally ill patients at district hospitals. The 72-hour observation is a particular area of difficulty throughout the country. This paper outlines the rationale and sense behind this legislation, discusses the problems encountered at the ‘rock face', and offers solutions to the problem of translating principles into practice.
This study in Western Cape South Africa shows that while immunisation coverage indicates that a lot of good work is being done, the coverage is insufficient to prevent outbreaks of measles and other common childhood conditions including polio. The coverage is too low to consider not running periodic mass campaigns for measles and polio. The coverage will need to be sustainably improved before introducing rubella vaccine as part of the EPI schedule. The reasons given by caregivers for their children not being immunised are valuable pointers as to where interventions should be focussed.
Inadequate patient tracking at one of South Africa's largest antiretroviral (ARV) distribution sites, has led to many patients disappearing from the clinic before treatment starts, a new report has found. The report by the Reproductive Health & HIV Research Unit (RHRU) of the University of the Witwatersrand, based on a 2006 review of patient files at the Tshepong Wellness Clinic, about 120km southwest of Johannesburg, shows that a standard percentage - about 14 percent - stop taking treatment, but more than 20 percent of patients never get to the treatment stage.
8. Human Resources
There is significant concern about the worldwide migration of nursing professionals from low-income countries to rich ones, as nurses are lured to fill the large number of vacancies in upper-income countries. This study explores the views of nursing students in Uganda to assess their views on practice options and their intentions to migrate. Improving remuneration for nurses is the top priority policy change sought by nursing students in this study. Nursing schools may want to recruit students desiring work in rural areas or public practice to lead to a more stable workforce in Uganda.
South Africa has large public and private sectors and there is a common perception that public sector hospitals are inefficient and ineffective while the privately owned and managed hospitals provide superior care and are more sustainable. The underlying assumption is that there is a potential gap in management capacity between the two sectors. This study aims to ascertain the skills and competency levels of hospital managers in South Africa and to determine whether there are any significant differences in competency levels between managers in the different sectors. The findings confirm the supposition that there is a lack of management capacity within the public sector in South Africa and that there is a significant gap between private and public sectors. It provides evidence that there is a great need for further development of managers, especially those in the public sector. The onus is therefore on administrators and those responsible for management education and training to identify managers in need of development and to make available training that is contextually relevant in terms of design and delivery.
Rich countries are poaching so many African health workers that the practice should be viewed as a crime, a team of international disease experts said. If one of these countries that is being systematically poached were to pursue it as a crime, contributing to unrest they would have some leg to stand on.
This World Health Organization background paper reviews and summarises service delivery management at the district level in Uganda. Specifically, it looks at health sector management development approaches that have been recently implemented, changes in the management capacity and performance and links between management development and health service delivery outputs. The paper finds that significant effort has gone into developing managers using long and short courses and placing "technical advisers" with District Health Management Teams. The paper concludes that whilst opportunities exist for managers to develop skills, courses need to be better designed to produce the essential competencies needed. A health sector competency framework for managers will provide common performance objectives and standards in the sector.
The growing AIDS epidemic in southern Africa is placing an increased strain on health systems, which are experiencing rising steadily patient loads. Health care systems are tackling the barriers to serving large populations in scaled-up operations. One of the most significant challenges in this effort is securing the health care workforce to deliver care in settings where the manpower is already in short supply. A demand-driven staffing model is presented in this study using simple spreadsheet technology, based on treatment protocols for HIV-positive patients that adhere to Mozambican guidelines. The model can be adjusted for the volumes of patients at differing stages of their disease, varying provider productivity, proportion who are pregnant, attrition rates, and other variables.
9. Public-Private Mix
As the World celebrates 30 years of the Alma Ata Declaration that launched the Primary Health as the Pillar of Quality services, there is greater need for all of us to improve access to affordable medicines. Even in rich countries, access to affordable medicines cannot be guaranteed. Of course, the problems are much greater in many developing countries, with insufficient or no manufacturing capacities in the pharmaceutical sector. In Africa we are too reliant on other countries to provide essential medicines for us. This is not strategic and correct, as we cannot guarantee availability of appropriate technologies that truly respond to our current and emerging needs.
Private health care has been specifically targeted for interventions by the health department in the coming year, according to South Africa Health Minister Manto Tshabalala-Msimang. She said the government was paying particular attention to 'improving accessibility and affordability of private health care.' The minister said that private hospitals were also agreeing to comply with the single exit price legislation with regard to the billing for anaesthetic gases which were previously overcharged. She said that the department was building on the progress made in regulating medicine prices to develop regulations that would allow the whole private health sector to be regulated.
The South Africa Minister of Health, Dr Manto Tshabalala-Msimang held separate follow-up meetings with representatives of the private hospital industry and medical schemes in Cape Town to discuss the challenge of increasing private health care costs. The Minister welcomed the efforts that have been made by some of the private hospital groups to adjust the tariff increases for 2008 towards the CPIX. However, there were concerns from schemes that adjustments announced have not translated to any savings that can be passed on to the consumer. The schemes reported on the efforts that have been made to reduce non-health costs in the medical schemes.
10. Resource allocation and health financing
Informal payments for health services are common in many countries, especially in transitional and developing countries. As part of a larger study focusing on health worker performance in Tanzania, one objective was to investigate the nature of informal payments in the health sector, and to identify mechanisms through which informal payments are affecting the quality of health services. A more profound understanding of these mechanisms is of interest because it may improve knowledge of how quality may be enhanced within a system where informal payments are common practice. The findings reveal a variety of positive and negative mechanisms through which informal payments may impact on the quality of health care. Furthermore, they show that informal payments add to health workers' incomes, thus contributing to the retention of workers in the health sector and to avoiding a further escalation of the current health worker shortage.
In the face of the dual TB/HIV epidemic, the ProTEST Initiative was one of the first to demonstrate the feasibility of providing collaborative TB/HIV care for people living with HIV (PLWH) in poor settings. The ProTEST Initiative facilitated collaboration between service providers. Voluntary counselling and testing (VCT) acted as the entry point for services including TB screening and preventive therapy, clinical treatment for HIV-related disease, and home-based care (HBC), and a hospice. This paper estimates the costs of the ProTEST Initiative in two sites in urban Zambia, prior to the introduction of anti-retroviral therapy. This study shows that coordinating an integrated and comprehensive package of services for PLWH is relatively inexpensive. The lessons learnt in this study are still applicable today in the era of ART, as these services must still be provided as part of the continuum of care for people living with HIV.
11. Equity and HIV/AIDS
The research in this book was carried out among banana-farming households in the districts of Masaka and Kabarole in Uganda. A gendered livelihood approach was used. The research focused on the identification of critical factors that need to be taken into consideration in the development of relevant policies for HIV/AIDS-affected agriculture-based households or those that are at risk. The book shows that HIV/AIDS causes significant negative effects on the lives of those affected. Their resources are affected due to HIV/AIDS-related labour loss and asset-eroding effects and disinvestment in production and child education. While in the overwhelming majority of the affected cases the effects of AIDS are negative and lead to increased impoverishment and vulnerability, for some households HIV/AIDS-related effects are manageable. It is concluded that a household's socio-economic status and demographic characteristics influence the magnitude of HIV/AIDS-related impacts experienced and capacity to cope. The book also highlights some historically specific social practices, policies, and ideologies that continue to maintain or reproduce distinct forms of inequality, with certain social groups being marginalized and others being privileged. Unless these are redressed, they will continue to aggravate people's vulnerability regardless of the type of shock that they are exposed to or experience.
The failure to remove barriers that determine whether a person can access and use a condom is one of the biggest impediments to preventing millions more HIV infections. This advocacy briefing from International Council of AIDS Service Organisations (ICASO) examines some of these barriers and addresses what can be done to overcome them. Information was sourced from a community-led monitoring project in 14 countries undertaken in 2005 and 2006 which collected and analysed data and information on the broad response to HIV and AIDS. The report states that to overcome prominent barriers, governments and donors around the world need to commit new resources and enact and reform legislation, policy and programming that will ensure condom access and availability. It argues that a mobilised community sector that can forcefully advocate for condom access is needed now more than ever.
This paper based on findings from the KwaZulu-Natal Income Dynamics Study (KIDS) describes caregivers’ perspectives on providing care for HIV positive family members. The paper focuses on understanding what care provision means to family caregivers and in turn why they provide care. More centrally it highlights various aspects of the experience of providing care and the effects of care on caregivers’ lives. Caregiver’s reported that caring is stressful and physically, emotionally and socially taxing. Moreover, in households in which care takes place there is in most cases a lack of resources to provide appropriate care. Almost all caregivers indicate that they do not always know what to do to provide care. The report recommends increased support for caregivers, namely training in how to provide the highest quality care possible such as delivering palliative care. This should be provided by home-based care organisations and health workers such as community health workers and nurses through home visits.
This research was undertaken to investigate what level of HIV knowledge medical staff have in a state hospital in South Africa. In particular it looks at their knowledge about and practical use of current HIV policy and counselling programmes within their hospital. The conclusions are applicable to other hospitals in South Africa. The report highlights several areas of poor knowledge. Education of medical staff may be insufficient due to several factors including lack of access to information, lack of training and counselling, and lack of knowledge about HIV policy. The authors recommend the effectiveness of current counseling services is evaluated and that hospital HIV policy and counselling programmes are developed in co- operation with community based organisations and all disciplines in the hospital, especially nurses.
The long wait is over. South Africa's HIV-positive pregnant women will now have access to medication that could further reduce the risk of passing the virus to their babies after the health department released guidelines for administering more effective dual therapy instead of single antiretroviral (ARV) treatment. The challenge now is to make sure that healthcare workers at public health facilities receive the guidelines and the medicines so that new mothers and babies will benefit as soon as possible.
The achievement of the Millennium Development Goals (MDGs) depends on sufficient supply of health workforce in each country. Although country-level data support this contention, it has been difficult to evaluate health workforce supply and MDG outcomes at the country level. The purpose of the study was to examine the association between the health workforce, particularly the nursing workforce, and the achievement of the MDGs, taking into account other factors known to influence health status, such as socioeconomic indicators. The main factors in understanding HIV prevalence rates are physician density followed by female literacy rates and nursing density in the country. Using general linear model approaches, increased physician and nurse density (number of physicians or nurses per population) was associated with lower adult HIV prevalence rate, even when controlling for socioeconomic indicators. Increased nurse and physician density are associated with improved health outcomes, suggesting that countries aiming to attain the MDGs related to HIV would do well to invest in their health workforce. Implications for international and country level policy are discussed.
12. Governance and participation in health
Tanzania initiated the Local Government Reform Programme in 1996. The objective of the reform is decentralisation by devolution, and to strengthen local authorities' ability to deliver quality and accessible services in cooperation with local communities, civil society organisations, the private sector, and other development actors. This report describes various forms of coordination and cooperation in four districts, using maternal health as an entry point and example. Four districts with relatively low maternal mortality rates were selected: Ileje, Misungwi, Serengeti, and Moshi rural. The objective of the study is to identify if, and in what ways, these districts perform better than others when it comes to cooperation on maternal health, and to identify best practices and disseminate the practices to other districts.
Local democracy and the involvement of local communities in the provision of social services are central issues in the local government reforms that are presently being implemented in many developing countries. At the same time, institutions that run parallel to local authorities, such as social funds and various user-committees, are established to improve accountability and participation. By focusing on actual political processes rather than administrative, legal, and fiscal aspects of decentralisation, this article traces the breakdown of two development projects in Tanzania to the existence of parallel structures, and suggests that user-committees and social funds should be integrated in local authority structures to avoid fragmentation of participation and to enhance local democracy.
Expectant mothers in Pallisa and Budaka districts have moved closer to realising their right to adequate reproductive health services, following the launch of HEPS Uganda's Community Empowerment and Participation on Maternal Health Project. The Project, falling within the empowerment, lobbying and advocacy themes of the EU's DSCBP, specifically targets expectant mothers, health care providers, district health officials and other local government leaders as well as community opinion leaders.
In the HIV/AIDS pandemic, it is older people, particularly grandmothers, who are shouldering most of the emotional and financial burden as carers. Yet their vital role is going unrecognised. This report calls for a major shift in the response to HIV/AIDS. Some of the recommendations include: public recognition of the value, contribution and rights of older women carers to reduce stigma and discrimination against them more sophisticated analysis and understanding of the role of older women and men in caring for adults and children living with HIV, so that urgent; support can be targeted at these older carers; better support to access existing services home-based care policies and programmes that address the specific economic, health and psychosocial needs of older women carers and support them in their care giving roles.
13. Monitoring equity and research policy
Primary health care (PHC) in South Africa forms an integral part of both the country's health policies and health system and has been prioritised as a major strategy in achieving health for all. On the eve of the 30th anniversary of the Alma Ata Declaration, PHC is once again in the spotlight. How far have we come in the last 30 years? How far in the last three? The third edition of the District Health Barometer, the 2006/07 report sheds some light by monitoring the trend of key health and financial indicators in PHC over the last three years by district and province.
Research plays a crucial role in developing solutions to the health problems suffered by the populations of low and middle income countries. Most health research for and in low and middle income countries is funded from external sources. And most of this externally funded research takes the form of 'vertical' - condition-specific - programmes. This paper begins by highlighting four important problems that result from reliance on this type of funding; including an unduly narrow focus of research on conditions for which international funding is available (mostly HIV and AIDS, tuberculosis, and malaria); lack of interest in leaving behind sustainable capacity in research after the research projects have ended; and loss of interest in the local programme at the time when research findings should be translated into action.
While the importance of promoting equity to achieve health is now recognised, the health gap continues to increase globally between and within countries. The description in this study looks at how the Cape Town Equity Gauge initiative, part of the Global Equity Gauge Alliance (GEGA) is endeavouring to tackle this problem. In two very different, but connected projects, the authors demonstrate the value of adopting the GEGA approach, and the importance of involvement of all stakeholders at all stages. The studies also illustrate the potential of a research institution as informed 'outsiders', in influencing policy and practice.
This report and summary deals with the findings of the survey that deal with the District Health Barometer (DHB) publication. The DHB aims at improving the quality of and access to primary health care through monitoring important aspects of the health system at a district level by analysing and comparing a carefully selected range of health indicators.
14. Useful Resources
Equal opportunities for health action for development is a project implemented by 29 European partners and associates from the health community with the aim to mobilise public support in Europe for Global Health and Health Equity as a strategy and policy for more equitable North-South relations and poverty reduction in developing countries.
APHRC’s research focuses on improving understanding of population and health issues through development and implementation of innovative, policy-oriented research programs to address the region’s key population and health challenges. APHRC’s research focus is organized into four themes: Urbanization and wellbeing; Population and Reproductive Health; Health Challenges and Systems; and Education. These research priorities have been selected to respond to needs identified by African governments and by multinational bodies and frameworks including the MDGs, the New Partnership for Africa's Development (NEPAD), the Economic Commission for Africa, the African Union, and the World Health Organization, among others. Within each theme, we particularly focus on areas where there are considerable knowledge gaps and where building on our past investments and current strengths holds the greatest potential to improve the wellbeing of Africans. Our methods include primary research projects where we collect new data; secondary analysis of existing data; synthesis of evidence; scenario building; and monitoring and evaluation of interventions. We also seek to develop and use new methodologies, partnering with other institutions as needed.
Local governments have an important role to play in enhancing the wellbeing of forest communities, yet often lack the capacity to understand and address local needs. This source book provides a useful resource for local governments, local communities, development practitioners and civil society organisations interested in reducing poverty through more participatory approaches with forest communities. They offer a positive concept of sustained human wellbeing and security that extends beyond sufficiency of income and food, and emphasises the potential role of forests in enhancing community wellbeing.
15. Jobs and Announcements
The African Population and Health Research Center (APHRC), in partnership with the International Development Research Centre (IDRC) and Ford Foundation, is pleased to announce the African Doctoral Dissertation Research Fellowships (ADDRF), a new fellowship program to support doctoral students at African universities whose theses address issues relating to heath systems strengthening in Africa. One of these fellowships will support doctoral research that focuses on the broad field of sexuality research. The deadline for applications is March 29, 2008. The ADDRF will award a maximum of 16 fellowships in the first year. These fellowships will be awarded to advanced doctoral students who are within two years of completing their doctoral thesis at an African university. Dissertation topics addressing health systems-related issues or sexuality from any disciplinary perspective are eligible for consideration.
This course is intended to equip Clinical and Medical Scientists, including Postgraduate Students involved in the Management of Research with Guidelines on Ethical Issues in Health Research. Topics include: The Meaning of Ethics; Ethics and Science; Informed Consent; Ethical Issues in Public Health Research, The Laboratory, Publication and the Pharmaceutical Industry; Risks, Harms and Benefits; Gender Issues in Research; Publication Ethics; and Research in Developing Countries. The Closing Date for applications is 7 March 2008. The course runs from 17 to 20 March 2008. Contact Rita Pike on cell number: (Zimbabwe) 011 608849.
Are you interested in fighting for access to treatment, prevention and care for people living with and at risk for HIV worldwide? Do you want to be an active part of winning big campaigns to treat millions of people with HIV and prevention millions more HIV infections? Then you should apply for Health GAP’s Grassroots Internship. Health Global Access Project (Health GAP) is an action-oriented advocacy group created in early 1999 by US-based AIDS and human rights activists, public health experts, fair trade advocates, and concerned individuals dedicated to expanding equitable access to treatment and care for people living with AIDS worldwide. Health GAP is hiring a Grassroots Intern for the remainder of the school year (May '08), starting as soon as possible. The position would be for 10 hours per week, and is unpaid (we will cover internship-related mobile phone and travel expenses).
Research for International Tobacco Control (RITC) of the International Development Research Centre (IDRC) is pleased to announce a Call for Letters of Intent for the African Tobacco Situational Analyses (ATSA). This competition is a joint initiative of RITC/IDRC and the Bill and Melinda Gates Foundation. The competition is administered by RITC/IDRC. The Call is available in English and French. A Portuguese translation will also be available shortly. The deadline for receipt of Letters of Intent is March 17, 2008 and will be accepted in English and French. Support for document translation from Portuguese to English or French will also be available.
The Institute of International Education's Scholar Rescue Fund (SRF) provides fellowships for established scholars whose lives and work are threatened in their home countries. These fellowships permit professors, researchers and other senior academics to find temporary refuge at universities and colleges anywhere in the world, enabling them to pursue their academic work and to continue to share their knowledge with students, colleagues, and the community at large. When conditions improve, these scholars will return home to help rebuild universities and societies ravaged by fear, conflict and repression. During the fellowship, conditions in a scholar's home country may improve, permitting safe return; if safe return is not possible, the scholar may use the fellowship period to identify a longer-term opportunity.
The Positive Living training based upon the book Positive Health is regarded as the bench-mark for interventions aimed at empowering people living with HIV or AIDS to take positive actions to maintain their health. The training targets Peer educators - Medical practitioners - Community workers – Wellness coordinators - EAP counsellors, HIV Champions; Health and Safety, VCT staff; CSI implementers; HR practitioners; as well as implementers for NGOs, VSOs, ASOs and FBOs. This training has formed the basis for corporate and government programs in 17 countries in Africa. The methods have been assessed by medical experts and were found to have solid credentials and cost-effectiveness.
The UN General Assembly has called for a high-level meeting on 10-11 June 2008, to undertake a comprehensive review of the progress achieved in realizing the 2001 Declaration of Commitment on HIV/AIDS and the 2006 Political Declaration on HIV/AIDS , as well as to promote the continued engagement of leaders in a comprehensive global response to AIDS. The high-level meeting will comprise plenary meetings, five thematic panel discussions and an informal interactive hearing with civil society. The outcome of the high-level meeting will be a Summary of the President of the General Assembly, reflecting the views expressed during the discussions. To facilitate civil society involvement in the high-level meeting and ensure an open, transparent and participatory process, the President of the General Assembly in partnership with UNAIDS will establish a Civil Society Task Force comprising representatives from civil society, the private sector and relevant UN focal points. The Task Force will, among other things, help identify participants for the civil society hearing and help determine the format, theme and programme. In addition, UNAIDS is working closely with a coalition of civil society organizations to provide support to civil society and community groups in maximizing the impact of the 2008 UN General Assembly high-level meeting on AIDS. Submit your application to attend the meeting at: http://www.un-ngls.org/unaids/en/application.php
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). Contact EQUINET at admin@equinetafrica.org and visit our website at www.equinetafrica.org
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