Beyond the call for governments to meet their commitment to spend 15% of their budgets on health, we are concerned to see that government spending reaches those with greatest health needs. So how well do governments perform in equitable allocation of their health spending?
In many African countries, health care spending levels are very different between different provinces, regions and districts. This is largely a historical inheritance. Health services, particularly hospitals which consume the major share of health care resources, are heavily concentrated in the largest urban areas, and rural areas are relatively under-resourced. Yet almost all countries in east and southern Africa have policy goals to provide equitable access to health care for their citizens. This implies that health care resources (financial, human and facilities) should be fairly distributed between geographic areas on the basis of health needs.
Internationally, it has been found that using a needs-based resource allocation formula is a helpful strategy for breaking the historical inertia in resource allocation patterns. Such formulae are used to distribute public sector health care resources between geographic areas (such as provinces or regions and districts) according to the relative need for health services in each area.
The indicators commonly used to identify relative levels of need for health services, and thus applied in these resource allocation formulae internationally are:
• population size;
• composition of the population, as young children, elderly people and women of childbearing age tend to have a greater need for health services;
• levels of ill-health, with mortality rates usually being used as a proxy for illness levels; and
• socio-economic status, given that there is a strong correlation between ill-health and low socio-economic status and that poor people rely most on publicly funded services.
A growing number of African countries have also adopted such needs-based formulae to guide the allocation of health care resources, using a mix of these indicators. How well then are we doing in the region in matching government spending on health to health needs?
A questionnaire survey of researchers and senior government officials in selected countries in the region (Namibia, South Africa, Zambia and Zimbabwe) carried out in the EQUINET work on fair financing showed that there has been progress in the equitable allocation of public sector health care resources over the past few years in the region. However, the extent of progress and pace of change varies between countries.
In both Zambia and Namibia, the most under-resourced provinces and regions have seen increased allocations, while allocations to provinces whose share of resources is proportionately greater than their share of health needs have been gradually reduced. Although South Africa has a different system where it allocates domestic public sector resources for health and other services as a ‘block grant’ to provinces, there has also been considerable progress towards equity in the distribution of health care resources in the past few years. In Zimbabwe, progress towards equity targets has been constrained by significant absolute shortfalls in health care resources, due to wider economic difficulties. In the main, however, the countries surveyed were generally making progress applying some form of needs based formulae in the region, with positive gains for districts with greater health needs.
Achieving this progress is underpinned by an explicit policy commitment to equity and to redistribution of resources. For example, the Namibian 1998 health policy states that “Particular emphasis shall be paid to resource distribution patterns in Namibia to identify and accelerate the correction of disparities”. South Africa, Zambia and Zimbabwe have made similar declarations.
Experience from countries in the region point to some of the actions countries need to take to overcome barriers in implementing equitable redistribution of their health care resources.
Countries need to set explicit annual allocation targets to provide clear goals against which progress can be planned and monitored. These targets need to set a reasonable pace of change for the relative redistribution of health care resources to facilitate appropriate planning and avoid unnecessary disruption to services.
Even where these targets exist, countries may need to overcome further difficulties in successfully pursuing these targets. There may be a lack of senior staff at the national level to drive the process. Numerous vertical programs that protect allocations to specific services reduce the pool of general health sector funds available for equitable allocation between geographic areas. It is difficult to translate budget shifts into real changes in expenditure without achieving the more difficult task of also changing the distribution of staff, given their importance in the uptake of resources. Strategies must thus be put in place to facilitate a relative redistribution of staff. This may include negotiations with trade unions and initiatives such as offering additional allowances, preferential training opportunities and other incentives to attract health workers to rural areas.
Resource allocation is a highly politicised process and the resource allocation policy development and implementation process requires careful management in order for it to be successful. The progress reported from the countries surveyed is a sign that these issues can be addressed.
It is politically and technically easier to address these issues and redistribute health care resources when the overall health budget is increasing. Our still limited progress by 2008 towards achieving the Abuja target of devoting 15% of government funds to the health sector thus limits our progress towards more equitable resource allocation. Those countries that are increasing the overall allocations to the health sector have more leeway to effectively redistribute health care resources. All of the additional budget available annually can be allocated to the most under-resourced areas while keeping the budgets of relatively over-resourced areas static in real terms (only allowing a small increase to take account of inflation). It is also an issue for those advocating the Abuja target to monitor that these additional funds are allocated to these areas of greatest health need.
The progress made in the region needs to be protected and advanced: Governments need to engage with and involve key stakeholders, including parliamentarians to ensure their ‘buy in’ to and understanding of the strategies for an equitable sharing of available resources. We have an increasing number of champions for the Abuja commitment. We also need ‘policy champions’ at senior level in Ministries of Health, civil society and parliament to motivate for and monitor progress in making sure that these resources for health are equitably allocated to where they are needed most..
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. EQUINET work on fair financing in health is available at the EQUINET website at www.equinetafrica.org.
1. Editorial
The World Health Organisation Director General (D-G) Margaret Chan described the recent WHO Executive Board meeting on 21-26 January 2008 as ‘stimulating, constructive and instructive.’ Chan challenged member states’ to provide her with direction regarding the contentious issues facing the WHO but the meeting failed to break the deadlock on issues regarding the selection criteria of the D-G and on how to deal with the International Migration of Health Personnel.
Developed countries opposed the inclusion of regional rotation in the selection criteria for the D-G, alleging that this may undermine the selection of competent candidates. However, many developing countries supported regional rotation as a selection criterion in order to promote balance amongst the regions who have had candidates as Directors-General, while not compromising on competence. The current selection process includes expensive campaign programmes that poor countries cannot afford to mount. Inclusion of the principle of rotation will go a long way to levelling the playing field.
The options presented in the Executive Board report on what the options were for addressing the proposed selection criteria changes were: (1) maintaining the status quo; (2) special consideration to candidates from certain regions; (3) and (4), two related options, considering geographical representation as the criterion for the establishment of the shortlist; (5) considering geographical representation as the criterion for the eligibility of candidates; and (6) using the same system of regional rotation as that applied to candidatures for elective office.
Board members supporting regional rotation of the post of D-G emphasised the need to ensure an equitable selection process and a level playing field among regions. They noted that no D-G had been appointed from three of the six WHO regions, even though qualified candidates from those regions had been proposed in past elections. Board members in favour of maintaining the current system said a pattern of regional rotation would necessarily restrict the choice of candidates, and would not therefore ensure that the most qualified person was elected.
One proposal was that the D-G be elected for 5 years with contribution until all the regions have contributed a D-G. Then it will start again, with the exclusion of the region of the outgoing D-G. While some supported this proposal, others, particularly from high income countries did not. It was proposed that the matter be set aside for two years, to give regions a chance to discuss the issue and the board would decide on it in 2009.
Member states were similarly divided on largely North-South lines on the issue of the international migration of health personal. Issues related to a global strategy, a code of practice, compensation mechanisms, a look into the failing training practices in the developed countries and better data for managing international health worker migration were raised in the discussions.
The developed countries position on WHO’s role on international migration was mainly for collecting information and developing non-binding codes of practice. Many developing countries, on the other hand sought effective actions including a global strategy and compensation. Member states adopted polarised positions and decision making was again deferred, which effectively maintains the existing status quo. Countries in Europe and North America pointed out that migration can have positive effects, such as migrants returning home with useful experience. However it was noted by other states that only 23 percent of the 130,000 health worker personnel abroad came back.
Attention was given to WHO work on the global code of practice, a matter seen to be a high priority for Africa. Without health workers, the Millennium Development Goals in Africa could not be achieved, and it was felt by some that the D-G should work with member states to come up with mechanisms for receiving countries to invest in training health workers in originating countries and assist with incentives.
Particularly raised by low and middle income member states was the observation that developed countries have failed in their own training policies and are now armed with ways of getting health personal from lower income countries, handicapping national health plans and deeply weakening the health systems of these source countries . It was raised that financial, equipment and technical support should be given in compensation, that certain discriminatory policies should come to an end and migrant workers receive the same salaries and benefits as paid to nationals of host countries. Further, headway was urged in developing effective measures to manage migration.
However, it was also noted that migration was a personal choice and that countries dealing with the impact of migration should create ‘task shifting to broaden the types of health workers’ who can provide care. Some members felt that a code of practice would not carry the weight of a ‘soft law’ as it was non-binding and not any kind of law, whether soft or otherwise.
While the WHO Secretariat reported that it was now getting better data and dialogue in place on migration a consultative process should now take place at the Executive Board meeting in 2009.
The debate on these two widely different issues signal that there is yet weak consensus within the WHO Executive Board on key contentious issues facing the WHO. There appears to be agreement on the need to act on such issues, but not yet on the direction of action. A division on “north-south” lines has maintained a deadlock on issues regarding the selection criteria of the D-G and on how to deal with the migration of health personnel. Their deferral for further consultation and review in 2009 contradicts the need for clear leadership on action, with action on health worker migration and retention particularly essential and urgent for developing countries affected.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. EQUINET work on health worker migration is available at the EQUINET website at www.equinetafrica.org.
2. Latest Equinet Updates
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.
We used participatory approaches 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; 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.
This poster presentation at the Global Health Worker Alliance Conference, March 2008, is based on a study that aimed to determine and assess the impacts of incentives instituted by the Zimbabwe government and non-government sector to retain Critical Health Professionals. It found that the tendency of health professionals to migrate has increased, even among low levels of staff and the macro-economic environment is the main driver of megration. Sustaining the retention incentives in this environment seems unattainable and bonding is unpopular and further increases migration.
The workshop is the third in a series run by TARSC and Ifakara on participatory reflection and action (PRA) methods in health, using a toolkit developed by TARSC and Ifakara in EQUINET, with support from IDRC and SIDA and peer review by CHESSORE Zambia. The PRA training focus in 2008 was on strengthening equitable primary health care responses to HIV and AIDS. The 2008 training aimed to build understanding of PRA approaches and their use in strengthening people centred health systems, particularly community focused and PHC oriented HIV and AIDS interventions. The workshop aimed to draw on experiences in the east and southern African region for strengthening community focused and PHC oriented HIV and AIDS interventions; work through practical examples of PRA approaches and their application in areas of work that participants are practically involved with at community level; provide initial mentoring and support to development of research and training proposals for EQUINET support on equitable, community driven responses.
3. Equity in Health
Tuberculosis (TB) is a major cause of illness and death worldwide, especially in Asia and Africa. Globally, 9.2 million new cases and 1.7 million deaths from TB occurred in 2006, of which 0.7 million cases and 0.2 million deaths were in HIV-positive people. Population growth has boosted these numbers compared with those reported by the World Health Organization (WHO) for previous years. More positively, and reinforcing a finding first reported in 2007, the number of new cases per capita appears to have been falling globally since 2003, and in all six WHO regions except the European Region where rates are approximately stable. If this trend is sustained, Millennium Development Goal 6, to have halted and begun to reverse the incidence of TB, will be achieved well before the target date of 2015. Four regions are also on track to halve prevalence and death rates by 2015 compared with 1990 levels, in line with targets set by the Stop TB Partnership. Africa and Europe are not on track to reach these targets, following large increases in the incidence of TB during the 1990s. At current rates of progress these regions will prevent the targets being achieved globally.
This paper sets out an initiative by African Development Bank, UNAIDS, UNFPA, UNICEF, WHO and the World Bank that aims to tackle barriers to scaling up health in Africa. The ‘Harmonisation for Health in Africa’ initiative HHA is a regional mechanism through which collaborating partners agree to focus on providing support to the countries in the African region for reaching health MDGs. The HHA initiative aims to: support countries to identify, plan and address health systems constraints to improve health related outcomes; develop national capacity through training, planning, costing and budgeting, harmonisation and stimulating peer exchange; promote the generation and dissemination of knowledge, guidance and tools for specific technical areas including strengthening health service delivery and monitoring health systems performance; support countries to leverage predictable and sustained resources for the health sector; ensure accountability and assist in monitoring performance, of national health systems, aid effectiveness and the performance of the International Health Partnership; and enhance coordination to support nationally owned plans and implementation process, helping countries to address the country level bottlenecks arising from constraints within international agencies.
The latest global maternal death statistics indicate that of the 536,000 women that died in 2005 of childbirth related complications, about half or 261,000 were African women. The recently released 2005 figures also indicate that Africa is the only region where maternal deaths have increased since 1990 up from 205,000. Maternal deaths dropped in every other continent over the same period. In Europe from 4,800 to 2,900, and in the America’s from 21,000 to 16,000. The prevalent maternal death risk also reflects a much bleaker picture of overall reproductive health in Africa. The Africa Public Health Rights Alliance “15% Now!” Campaign has developed a scorecard based on the 2005 figures and available comparable global health financing and health systems data. The scorecard shows that in the bottom 10 countries globally - all of which are African except Afghanistan, maternal death risk is between 1 in 7 (Niger) and 1 in 15 (Mali). In the top 10 the risk is between 1 in 47,600 (Ireland) and 1 in 13,800 (Switzerland). Possibly every family in the bottom 10 countries will suffer 1 maternal death. Overall 1 in 23 African women have a lifetime risk of maternal death compared with 1 in 2,300 in Europe.
World Health Day, on 7 April, marks the founding of the World Health Organization and is an opportunity to draw worldwide attention to a subject of major importance to global health each year. In 2008, World Health Day focuses on the need to protect health from the adverse effects of climate change. The theme “protecting health from climate change” puts health at the centre of the global dialogue about climate change. WHO selected this theme in recognition that climate change is posing ever growing threats to global public health security. Through increased collaboration, the global community will be better prepared to cope with climate-related health challenges worldwide. Examples of such collaborative actions are: strengthening surveillance and control of infectious diseases, ensuring safer use of diminishing water supplies, and coordinating health action in emergencies.
4. Values, Policies and Rights
After years of relative neglect, the World Health Organization has recently given strategic prominence to the development of primary health care. This year sees the 30th anniversary of the declaration of Alma Ata. Primary health care 'based on practical, scientifically sound and socially acceptable methods and technology made universally accessible through people’s full participation and at a cost that the community and country can afford' was to be the key to delivering health for all by the year 2000. Primary health care in this context includes both primary medical care and activities tackling determinants of ill health.
Since the beginning of the HIV epidemic, governments and the private sector have implemented travel restrictions with regard to HIV positive people wishing to enter or remain in a country for a short stay (e.g. business, personal visits, tourism) or for longer periods (e.g. asylum, employment, immigration, refugee resettlement, or study). UNAIDS has set up an international task team to heighten attention to the issue of HIV-related travel restrictions (both short-term and long-term) on international and national agendas and move towards their elimination.
In the light of Millennium Development Goals No.1 – to eradicate extreme poverty and hunger – and No.3 – to promote gender equality and empower women – the present study provides a cross-cutting analysis of the right to food from a gender perspective, examining relevant international instruments as well as State practice. The analysis of these documents will give an idea of what is today’s level of awareness of women’s right to food and related issues, how much is covered by law and how much is missing.
5. Health equity in economic and trade policies
This document presents the first volume of results from a survey on the Paris Declaration. It provides an overview of the key findings across the 34 countries involved, as well as assessing the survey process and setting out key conclusions and recommendations. Key implications of the survey that are highlighted include higher expectation levels for reform, deeper ownership and more accountable institutions, and increasing aid efficiency together with donor harmonisation. The authors suggest that aid effectiveness issues and results need to be discussed more explicitly at country level, and credible monitoring mechanisms need to be developed. If countries and donors are to accelerate progress towards achieving the Paris Declaration commitments, it is recommended that: partner countries must deepen their ownership of the development process; donors need to support these efforts by making better use of partners' capacity; to further harmonisation, donors must work aggressively to reduce the transaction costs of delivering and managing aid; and to begin addressing mutual accountability commitments, countries and donors should clearly define a mutual action agenda.
Although the Swazi government has reaffirmed its commitment to the second phase of negotiations towards a full EPA (economic partnership agreement) with the European Union (EU), which relates to trade in services and investment, economists continue to argue that it will be detrimental to the domestic industry. Economist Thembinkosi Dlamini stated: “If one looks at the EPA for what it really is, it is clear that it wants those things that are under the Doha Development Agenda, that is, trade in services and investment as well as government procurement.” He said that Swaziland or the Southern African Development Community (SADC) would not be able to compete with a European company for trade in services.
Trade talks between the European Union and southern African countries have opened up serious differences between Europe and South Africa, and between South Africa and her neighbours. At the heart of the difficulties are the Economic Partnership Agreements (EPAs) which countries of the African, Caribbean and Pacific (ACP) grouping are negotiating to get preferential access to European markets. A number of southern African countries have just signed an Interim EPA (IEPA) with Europe but South Africa has baulked at signing, threatening the future of the Southern African Customs Union – the world's oldest.Resolving the difficulties will require a lot of political will and sensitivity from both South Africa and the EU, writes AllAfrica guest columnist Nkululeko Khumalo of the South African Institute of International Affairs.
Developing country governments will struggle to invest in decent public health facilities when valuable resources are needed to service debt. However, the evidence is that debt relief works to alleviate healthcare shortages - spending on health in countries that have received debt cancellation has risen by seventy percent. The report calls for urgent action to ensure developing countries’ can provide adequate healthcare: rich countries, institutions and commercial creditors must cancel all illegitimate (i.e. due to ‘unfair or irresponsible’ lending) and unpayable debts being claimed from all poor countries, not just those eligible for the Highly Indebted Poor Country (HIPC) Initiative; creditors should recognise debtor governments’ accountability to their own citizens, and not impose economic policies through conditions on debt relief or loans. This includes conditions limiting public spending or specifying how healthcare should be delivered; and southern governments must abide by the demands of their citizens that funds from debt cancellation be used to improve essential public services – and the governments must be open and accountable to their people over the use and monitoring of these funds.
The paper argues that politics is central to aid effectiveness and the measures should be taken to ensure democratic ownership of citizens in recipient countries. It argues that aid must ensure mutual accountability between donors, government and citizens. Furthermore, donors need to ensure high standards of aid quality by fairly allocating aid toward poverty reduction, untying aid and limiting technical assistance, as well as ensuring predictability for recipient countries. The paper makes a number of recommendations ahead of the Accra High Level Forum on aid effectiveness, which include: donors should recognise the centrality of poverty reduction, equality and human rights; all donor-imposed policy conditionality should be ended; donors and Southern governments must adhere to the highest standards of openness and transparency; donors should recognise CSOs as development actors in their own right and acknowledge the conditions that enable them to play effective roles in development; an effective and relevant independent monitoring and evaluation system for the Paris Declaration and its impact on development outcomes should be developed; mutually agreed, transparent and binding contracts to govern aid relationships should be introduced; and new multi-stakeholder mechanisms for holding governments and donors to account should be created.
Intellectual property rights are affecting human rights in several areas such as public health, access to knowledge and agriculture, and human rights advocates have a decisive role to play to reverse the trend, according to members of a recent panel discussion on the negative impacts of intellectual property systems. The event organised on 13 March by the International Environmental Law Research Centre (IELRC) and 3D -> Trade - Human Rights - Equitable Economy in cooperation with the United Nations Office of the High Commissioner for Human Rights, brought together speakers whose primary aim was to provide entry points and opportunities for human rights advocates to challenge the current trend in intellectual property policy-making.
The Senate Foreign Relations Committee voted to reauthorize the President’s Emergency Plan for AIDS Relief at a cost of $50 billion over the next five years. No amendments were considered presently for the senate bill introduced by Sen. Biden of Delaware. Of the $50 billion, $4 billion would be allocated to tuberculosis programs and another $5 billion for malaria programs.
EU trade chief Peter Mandelson dangled a carrot in front of SA's negotiators at the weekend, hinting at greater access to European markets in exchange for SA returning to the negotiating table to resolve a standoff over a stalled regional trade deal with the EU. But his promises may not be enough to persuade SA. SA's chief trade negotiator, Xavier Carim, said that improved market access - evidently offered on agriculture, fisheries and industrial goods - did not ease concern that EU demands would limit SA's policy options.
GlaxoSmithKline (GSK) has begun a scheme of tiered pricing of its medicines in low- and middle-income countries. The policy is being tested in India, South Africa and Morocco, to ensure the greatest availability of their products, while still recovering R&D costs from those who are able to pay.
6. Poverty and health
With increasing urbanisation in sub-Saharan Africa and poor economic performance, the growth of slums is unavoidable. About 71% of urban residents in Kenya live in slums. Recent research shows that the urban poor fare worse than their rural counterparts on most health indicators, yet much about the health of the urban poor remains unknown. This study aims to quantify the burden of mortality of the residents in two Nairobi slums, using a Burden of Disease approach and data generated from a Demographic Surveillance System. Slum residents in Nairobi have a high mortality burden from preventable and treatable conditions. It is necessary to focus on these vulnerable populations since their health outcomes are comparable to or even worse than the health outcomes of rural dwellers who are often the focus of most interventions.
7. Equitable health services
This paper reviews 58 studies that assess the delay in the diagnosis and treatment of tuberculosis (TB). Delay in diagnosis can affect disease prognosis at the individual level and enhance transmission of TB within the community. The paper identifies the main factors associated with diagnostic delay. These include HIV; coexistence of chronic cough and/or other lung diseases; geographical barriers; rural residence; poverty; old age; female sex; alcoholism and substance abuse; low educational level; low awareness of TB; and stigma. The paper concludes that the core problem in delay of diagnosis and treatment appears to be a vicious cycle of repeated visits at the same healthcare level, resulting in non-specific antibiotic treatment, incorrect diagnosis and failure to access specialised TB services. Three groups of healthcare providers were identified as sources of this vicious cycle: primary-level government health posts who have limited diagnostic facilities and poorly trained personnel; private practitioners with low awareness of TB and unqualified vendors and traditional practitioners.
The Pan African meeting on access to essential medicines (AEM) and rational use of medicines (RUM) was convened by Health Action International (HAI) Africa and the Ecumenical Pharmaceutical Network (EPN)2 on 14th and 15th November 2007 in Nairobi, Kenya. The meeting brought together African experts and stakeholders from the pharmaceutical sector, including civil society organizations (CSOs) and faith-based organizations (FBOs), to discuss issues around AEM and RUM.
In this community-based cross-sectional survey among rural pregnant women in western Kenya, a medical, obstetric and reproductive history was obtained. Blood was obtained for a malaria smear and haemoglobin level, and stool was examined for geohelminths. Height and weight were measured. In this rural area with a high HIV prevalence, the reported use of condoms before pregnancy was extremely low. Pregnancy health was not optimal with a high prevalence of malaria, geohelminth infections, anaemia and underweight. Chances of losing a child after birth were high. Multiple interventions are needed to improve reproductive health in this area
The principal challenge to achieving the Abuja Declaration goal was to develop an efficient, equitable and sustainable mechanism to deliver insecticide treated nets to the poor and most vulnerable segments of the population. One method—social marketing, employs the principles and practices of commercial marketing techniques to deliver socially beneficial goods at affordable, and often, at subsidized prices to particular groups. Social marketing of insecticide treated nets, through a public-private partnership and meaningful community participation in Tanzania, has successfully and quickly increased the distribution of mosquito nets among the poorest populations, particularly children and pregnantwomen. This program has resulted in improved health outcomes with respect to morbidity and mortality impact of Malaria on the population of children.
The Code of Conduct for Health Systems Strengthening is a response to the recent growth in the number of international non-governmental organizations (INGOs) associated with increase in aid flows to the health sector. It is intended as a tool for service organizations – and eventually, funders and host governments. The code serves as a guide to encourage NGO practices which contribute to building public health systems and discourage those which are harmful. The working document was drafted by a coalition of activist or service delivery organizations, including Health Alliance International, Partners in Health, Health GAP, and Action Aid International. EQUINET also contributed to the consultations on the code. It will be revised in a series of consultations over 2008.
8. Human Resources
This presentation was given at the First Forum on Human Resources for Health in Kampala. It describes a study to identify the level of satisfaction and intent to stay among health workers, to inform strategies to improve retention.
Pages
9. Public-Private Mix
The owners of for-profit private hospitals have voted themselves to maintain high-cost-high profits health care system, in defiance of the modest call by the Minister to act in favour of health before profits. NEHAWU alleges that the refusal by private hospital companies to reduce the tariff increases, at least to the CPIX level, demonstrates once again why profit maximization in health care is incompatible with the needs of society as a whole. The organisatiion further observes in their report that much of the healthcare costs in the private health sector have nothing to do with provision of quality care, but spending on unnecessary and expensive equipment, hospital and office infrastructure and profits for their shareholders. NEHAWU does not believe however that the solution lies in another effort at regulation and calls for fundamental transformation of the sector, especially in the medical schemes and for-profit private hospital sector which command huge resources required for re-distribution in favour of the majority not the minority.
The South African Health Review (SAHR) is an annual publication of the Health Systems Trust (HST), which has been published since 1995. The SAHR seeks to provide a South African perspective on prevailing international public health issues, to stimulate debate and critical dialogue and to provide a platform for assessing progress in the health sector.
The private sector provides care for about 7 million people or close to 15% of all South Africans but consumes more than the total expenditure by the public health sector. The per capita expenditure in the private health sector is about 8 times more than that in the public health sector. Put another way, the public health sector spends about R1000 per patient per year whilst the private sector spends about R8000. The private sector spends an estimated 5.5% of gross domestic product. In addition, this sector employs more doctors, pharmacists and dentists than the public health sector. Clearly, this level of inequity cannot be left unchallenged.
The purpose of this study is to review the research literature on the effectiveness of contracting-out of primary health care services and its impact on both programme and health systems performance in low- and middle-income countries. Due to the heightened interest in improving accountability relationships in the health sector and in rapidly scaling up priority interventions, there is an increasing amount of interest in and experimentation with contracting-out. Overall, while the review of the selected studies suggests that contracting-out has in many cases improved access to services, the effects on other performance dimensions such as equity, quality and efficiency are often unknown. Moreover, little is known about the system-wide effects of contracting-out, which could be either positive or negative. Although the study results leave open the question of how contracting-out can be used as a policy tool to improve overall health system performance, the results indicate that the context in which contracting-out is implemented and the design features of the interventions are likely to greatly influence the chances for success.
10. Resource allocation and health financing
Advocates for many developing-world health and population issues have expressed concern that the high level of donor attention to HIV/AIDS is displacing funding for their own concerns. Even organizations dedicated to HIV/AIDS prevention and treatment have raised this issue. However, the issue of donor displacement has not been evaluated empirically. This paper attempts to do so by considering donor funding for four historically prominent health agendas—HIV/AIDS, population, health sector development and infectious disease control—over the years 1992 to 2005. The paper employs funding data from the Organization for Economic Cooperation and Development's (OECD) Development Assistance Committee, supplemented by data from other sources. Several trends indicate possible displacement effects, including HIV/AIDS’ rapidly growing share of total health aid, a concurrent global stagnation in population aid, the priority HIV/AIDS control receives in US funding, and HIV/AIDS aid levels in several sub-Saharan African states that approximate or exceed the entirety of their national health budgets. On the other hand, aggregate donor funding for health and population quadrupled between 1992 and 2005, allowing for funding growth for some health issues even as HIV/AIDS acquired an increasingly prominent place in donor health agendas. Overall, the evidence indicates that displacement is likely occurring, but that aggregate increases in global health aid may have mitigated some of the crowding-out effects.
If health insurance is to cover broader population strata in sub-Saharan Africa and to assure satisfactory health services, schemes will require continuous and long-term subsidies to bridge the gap between household capacity to contribute financially and the real costs of health care. The development of approaches addressing this dilemma should be considered as a research priority. They might include initiatives of north–south risk pooling. This necessity is underpinned by the capacity of health insurance to formalise social protection and create a market between health service providers and their “customers”, simultaneously alleviating poverty and empowering communities. Yet, available evidence points out that to play these roles, health insurance needs subsidies.
Cost-effectiveness analysis as an aid to decision making has been increasingly publicized and discussed during the past two to three decades. However, the total body of cost-effectiveness analyses in health care is actually rather small, and high-quality studies are rather rare. Furthermore, the applications of economic analysis to health policy have been hampered by a number of problems, including those that are methodological and contextual. We consider a number of areas of public health policy but pay special attention to a growing area of inquiry and application: the overall coverage of health services. Cost-effectiveness analysis has played a relatively small role in general coverage decisions, but in recent years, it has been applied increasingly to decisions concerning pharmaceutical coverage. We speculate on concerning reasons for this particular focus in cost-effectiveness analysis. Future progress will depend heavily on discussion and consensus building.
Policy makers and programme managers require more detailed information on the cost and impact of packages of evidenced-based interventions to save newborn lives, particularly in South Asia and sub-Saharan Africa, where most of the world's 4 million newborn deaths occur. This study estimated the newborn deaths that could be averted by scaling up 16 interventions in 60 countries. We bundled the interventions in a variety of existing maternal and child health packages according to time period of delivery and service delivery mode, and calculated the additional running costs of implementing these interventions at scale (90% coverage) in sub-Saharan Africa and South Asia. The phased introduction and expansion of interventions was modelled to represent incremental strategies for scaling up neonatal care in developing country health systems. Low-cost, effective newborn health interventions can save millions of lives, primarily in South Asia and sub-Saharan Africa. Modelling costs and impact of intervention packages scaled up incrementally as health systems capacity increases can assist programme planning and help policy makers and donors identify stepwise targets for investments in newborn health.
How does health insurance affect health? After reviewing the evidence on this question, we reach three conclusions. First, many of the studies claiming to show a causal effect of health insurance on health do not do so convincingly because the observed correlation between insurance and good health may be driven by other, unobservable factors. Second, convincing evidence demonstrates that health insurance can improve health measures of some population subgroups, some of which, although not all, are the same subgroups that would be the likely targets of coverage expansion policies. Third, for policy purposes we need to know whether the results of these studies generalize. Solid answers to the multitude of important questions about how specific health insurance policy options may affect health seem likely to be forthcoming only with investment of substantial resources in social experiments.
11. Equity and HIV/AIDS
At the 2006 United Nations High Level Meeting on HIV/AIDS, world leaders reaffirmed that “the full realization of all human rights and fundamental freedoms for all is an essential element in the global response to the HIV/AIDS pandemic.” Yet, 25 years into the AIDS epidemic, this “essential element” remains the missing piece in the fight against AIDS. Now more than ever, law and human rights should occupy the center of the global HIV/AIDS struggle. This booklet, published by OSI's Law and Health Initiative, presents 10 reasons why.
This paper highlights the socio-economic impacts of HIV on women. It argues that the socio-cultural beliefs that value the male and female lives differently lead to differential access to health care services. The position of women is exacerbated by their low financial base especially in the rural community where their main source of livelihood, agricultural production does not pay much. But even their active involvement in agricultural production or any other income ventures is hindered when they have to give care to the sick and bedridden friends and relatives. This in itself is a threat to household food security. The paper proposes that gender sensitive policies and programming of intervention at community level would lessen the burden on women who bear the brunt of AIDS as caregivers and livelihood generators at household level. Improvement of medical facilities and quality of services at local dispensaries is seen as feasible since they are in the rural areas. Other interventions should target freeing women's and girls' time for education and involvement in income generating ventures. Two separate data sets from Western Kenya, one being quantitative and another qualitative data have been used.
Active tuberculosis (TB) is common among HIV-infected persons living in tuberculosis endemic countries, and screening for tuberculosis (TB) is recommended routinely. The study sought to determine the role of chest x-ray and sputum culture in the decision to treat for presumptive TB using active case finding in a large cohort of HIV-infected patients. Many ambulatory HIV-infected patients with CD4 counts >200/mm3 are treated for presumptive TB. Data suggests that optimal detection requires comprehensive evaluation, including CXR and sputum culture on both symptomatic and asymptomatic subjects.
PRESIDENT Yoweri Museveni of Uganda has called for death penalty for people who knowingly spread HIV. He also called for the outlawing of primitive methods used by the Bagishu and Sebei in eastern Uganda of using knives for circumcision that are likely to spread the virus. Speaking at the commemoration of 25 years since the first case was identified at Kasensero landing site in Rakai District on Friday, the President lauded the parliamentary committee on HIV/AIDS for coming up with the draft Bill.
The first global consultation led by people living with HIV to address their sexual and reproductive health (SRH) and rights took place in Amsterdam, The Netherlands, 5-7 December 2007. The international group of 65 HIV-positive women, men, young people, and transgender people articulated a vision statement to guide advocacy, policy, legal, programmatic and funding priorities that respect SRH and rights, and that underscores the need for health systems to do the same.
Researchers conducted a retrospective cohort study analysing data on patients who presented to McCord Hospital, Durban, and started ART between 1 January 1999 and 29 February 2004. Univariate and multivariate analysis were performed and Kaplan-Meier curves were created to assess predictors. Simple clinical and laboratory data independently predict mortality and allow for risk stratification in patients initiating ART in South Africa. Interventions enabling patients to be identified before they develop these clinical markers and earlier initiation of ART will help to ensure maximum benefits of therapy.
There are the four pillars that will ensure that Africa and Asia are both able to respond to the challenges of HIV and also apply the painful lessons learned from this epidemic in cultures and societies that may – at first glance – seem so different. These are: Visionary leadership; people-centred policies; innovative evidence-informed programmes and passionate participation.
Under the Global Coalition on Women and AIDS (GCWA), the International Planned Parenthood Federation (IPPF), together with the United Nations Populations Fund (UNFPA) and Young Positives are developing 23 country Report Cards with the aim to strengthen HIV Prevention strategies for girls and young women. Each Report Card provides a country profile, information on HIV prevention from the legal, policy, service availability and accessibility, rights and participation perspectives and includes quotes and issues raised by young women and girls of the country. They also discuss key social and cultural issues, including the role of men and boys in HIV prevention. These form the basis for a series of recommendations aimed at increasing and improving the programmatic, policy and funding actions taken on HIV prevention for young women and girls, targeting national, regional and international decision makers. Follow- up work from these report cards has also shown that facilitating dialogue between young women and girls and national stakeholders in an open forum, can have a direct and positive influence on both policy and programmes. It also helps to develop the leadership skills of the young women so that they can take their future into their own hands.
Rural women living with HIV in circumstances of poverty in South Africa face discrimination in relationships and in communities because of their gender, HIV status and economic marginalisation. A new Amnesty International report based on interviews with rural women, the majority of them living with HIV, exposes the overwhelming challenges they face in the midst of the severe HIV epidemic affecting the country. Despite gradual improvements in the government's response to the HIV epidemic and the adoption of a widely-welcomed five-year plan, five and a half million South Africans are HIV-infected – one of the highest numbers in any country in the world. Fifty-five percent of them are women. South African women under 25 are between three and four times more likely to be HIV-infected than men in the same age group.
Limited research has been conducted outside Western settings on how HIV-positive parents decide to test and disclose their own HIV status to children. This qualitative study was conducted in 2001 and 2005 to assess parent attitudes and current counselling policy and practice regarding child testing and parental disclosure in Uganda prior to the roll-out of antiretroviral therapy. Concerns over disclosure to children of parent's HIV status and testing children for HIV represent a major psychological burden for HIV-positive parents. Further research is reported to be needed, but current counselling practice could be improved now by adapting lessons learned from existing research.
12. Governance and participation in health
There is increasing interest among health policymakers, planners and donors in how corruption affects health care access and outcomes, and what can be done to combat corruption in the health sector. Efforts to explain the risk of abuse of entrusted power for private gain have examined the links between corruption and various aspects of management, financing and governance. Behavioural scientists and anthropologists also point to individual and social characteristics which influence the behaviour of government agents and clients. This article presents a comprehensive framework and a set of methodologies for describing and measuring how opportunities, pressures and rationalizations influence corruption in the health sector. The article discusses implications for intervention, and presents examples of how theory has been applied in research and practice. Challenges of tailoring anti-corruption strategies to particular contexts, and future directions for research, are addressed.
There is growing concern that health policies and programmes may be contributing to disparities in health and wealth between and within households in low-income settings. However, there is disagreement concerning which combination of health and non-health sector interventions might best protect the poor. Potentially promising interventions include those that build on the social resources that have been found to be particularly critical for the poor in preventing and coping with illness costs. In this paper we present data on the role of one form of social resource— community-based organisations (CBOs)—in household ability to pay for health care on the Kenyan coast. Data were gathered from a rural and an urban setting using individual interviews (n = 24), focus group discussions (n = 18 in each setting) and cross-sectional surveys (n = 294 rural and n = 576 urban households). We describe the complex hierarchy of CBOs operating at the strategic, intermediate and local level in both settings, and comment on the potential of working through these organisations to reach and protect the poor. We highlight the challenges around several interventions that are of particular international interest at present: community-based health insurance schemes; micro-finance initiatives; and the removal of primary care user fees. We argue the importance of identifying and building upon organizations with a strong trust base in efforts to assist households to meet treatment costs, and emphasize the necessity of reducing the costs of services themselves for the poorest households.
The increasing use of participatory research (PR) approaches to address pressing public health issues reflects PR's potential for bridging gaps between research and practice, addressing social and environmental justice and enabling people to gain control over determinants of their health. This critical review of the PR literature culminates in the development of an integrative practice framework that features five essential domains and provides a structured process for developing and maintaining PR partnerships, designing and implementing PR efforts, and evaluating the intermediate and long-term outcomes of descriptive, etiological, and intervention PR studies. the paper reviews the empirical and nonempirical literature in the context of this practice framework to distill the key challenges and added value of PR. Advances to the practice of PR over the next decade will require establishing the effectiveness of PR in achieving health outcomes and linking PR practices, processes, and core elements to health outcomes.
13. Monitoring equity and research policy
The complex evidence-policy interface in low and middle income country settings is receiving increasing attention. Future Health Systems (FHS): Innovations for Equity, is a research consortium conducting health systems explorations in six Asian and African countries: Bangladesh, India, China, Afghanistan, Uganda, and Nigeria. Three key activities were undertaken during the initial phase of this five-year project: key considerations in strengthening evidence-policy linkages in health system research were developed through workshops and electronic communications; four considerations were applied to research proposals in each of the six countries to highlight features in the research plans that potentially strengthen the research-policy interface and opportunities for improvement; and utility of the approach for setting research priorities in health policy and systems research was reflected upon. Developmental consideration with four dimensions a poverty, vulnerabilities, capabilities, and health shocks a provides an entry point in examining research-policy interfaces in the six settings. Research plans focused upon on the ground realities in specific countries strengthens the interface. Focusing on research prioritised by decision-makers, within a politicised health arena, enhances chances of research influencing action. Early and continued engagement of multiple stakeholders, from local to national levels, is conducive to enhanced communication at the interface.
This paper presents the methodology and findings from a proof-of-concept study undertaken to explore the viability of conducting a systematic, largely qualitative synthesis of evaluation reports emanating from Community Based Rehabilitation (CBR) projects in developing countries. Computer assisted thematic qualitative analysis was conducted on recommendation sections from 37 evaluation reports, arising from 36 disability and development projects in 22 countries. Quantitative overviews and qualitative summaries of the data were developed. The application of the synthesis methodology utilised in this proof-of-concept study was found to be potentially very beneficial for future research in CBR, and indeed in any area within health services or international development in which evaluation reports rather than formal research evidence is the primary source material. The proof-of-concept study identified a number of limitations which are outlined. Based on the conclusions of 37 evaluation reports, future policy frameworks and implementation strategies in CBR should include a stronger emphasis on technical, organisational, administrative and personnel aspects of management and strategic leadership.
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.
14. Useful Resources
The purpose of this book is to provide guidance in understanding how the WTO institutions and agreements that impact the agricultural sector operate. Its aim is to provide those in charge of civil society organisations in sub-Saharan Africa with tools and references to better understand the stakes behind, and means for, their participation in worl trade. Organised around descriptive and factual texts, this work contains many definitions and is illustrated by concrete experiences that facilitate reading.
Progress in quantifying and understanding health equities would not have been possible without appropriate analytic techniques. These techniques are the subject of this book, which includes chapters dealing with data issues and the measurement of the key variables in health equity analysis, quantitative techniques for interpreting and presenting health equity data, and the application of these techniques in the analysis of equity in health care utilisation and health care spending. The aim of the book is to 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. It is hoped that these step-by-step guides, and the easy-to-implement computer routines contained in them, will help stimulate yet more research in the field, especially policy-oriented health equity research that enables researchers to help policymakers develop and evaluate programs to reduce health inequities.
This Guide documents pioneering methodologies used by civil society organizations around the developing world to hold their governments to account for the use of public resources. Specific methodologies examined by the Guide include social audits, citizen report cards, public expenditure tracking surveys, procurement monitoring tools, and participatory auditing tools. These methodologies are considered in detailed case studies presenting the work of 17 organizations from 12 countries in Asia, Africa, and Latin America. The Guide will enable readers to gain familiarity with the typical processes followed by national-level governments during the execution of budgets, management of procurements, measurement of impact achieved by expenditures, and oversight of budget expenditures through audits and legislative supervision. For each of these processes, the Guide provides practical tools and techniques that readers can use to monitor the results achieved by government expenditures.
15. Jobs and Announcements
As the conference draws near and many deadlines have already passed, we urge those wishing to attend AIDS 2008 - or submit a satellite, exhibition or affiliated event application - to be aware of the limited time left to do so. Please note that all deadlines from now refer to 24h00 in the country you are submitting from on the given date and that no applications and submissions for any part of the conference will be accepted after this time: 31 March 2008: Satellites applications close; 7 May 2008: Registration late surcharge ends (last minute surcharge begins 8 May), Deadline for registration cancellation (with 50% refund); 15 May 2008: Affiliated Events applications close; 20 May 2008: Late Breaker Abstract submissions open; 31 May 2008: Exhibitions applications close; 16 June 2008: Late Breaker Abstract submissions close.
The 2008 Global Ministerial Forum will assess progress over the last 20 years and commitments from earlier conferences. It subsumes the Global Forum's 2008 meeting, Forum 12. Bamako 2008 will look at current challenges and place health research and innovation within the wider context of research for development. While political momentum for strengthening research in and by low- and middle-income countries is growing, much remains to be done. The three key objectives of the Forum are to: Strengthen leadership for health, equity and development; Engage all relevant constituencies in research and innovation for health; and Increase accountability of research systems. The Forum aims to generate specific recommendations and commitments, culminating in an action plan to strengthen research for health, development and equity.
The Ministerial Leadership Initiative (MLI) is soliciting submissions to participate in its program of support. On a competitive basis, MLI will select four or five countries (or States or Provinces in big countries like India) to support with technical assistance and peer learning opportunities over a three year period. The submissions need to show that the country/State is engaging in pro-poor financing reforms and/or in efforts to harmonise and align external assistance. The submissions are short (max 5 pages) and they are due 25 April 2008.
The Centre for Applied Social Sciences (CASS), University of Zimbabwe with the support of the Biomedical Research and Training Institute’s NIH funded International, Clinical, Operational, and Health Services Research Training Award (ICOHRTA) programme, is delighted to announce a short training course on ‘Communicating Scientific Research on HIV and AIDS to Policy Makers and Practitioners.’ There is no doubt that there is abundant research on HIV and AIDS. The biggest question is whether that research is translated into policy and action capable of improving the condition of those living with the disease. Something needs to be done if researchers must escape the charge of being irrelevant. The course is designed to assist researchers and students to better communicate research on HIV and AIDS to those with the capacity to develop policy and plans that can improve the condition of people affected and infected with HIV and AIDS.
The 2008 Conference marks the thirtieth anniversary of the WHO/UNICEF Conference on Primary Health Care held in Alma Ata, USSR (now Kazakhstan). Primary Health Care remains the strategy of WHO for achieving Health for All and is the philosophy informing South Africa's health policies. There is currently renewed interest globally in Primary Health Care and the potential of this approach to address continuing health and health care challenges, not least in addressing the major problems of HIV, TB and malaria. PHASA is dedicating its 2008 Conference to PHC in recognition of the above and in the hope that research presented and ensuing discussions will assist in defining more precisely the role of Public Health in developing PHC to implement South Africa's bold health policies.
Is the world doing enough to stop AIDS? Take action in your country and show solidarity globally. Join a groundswell of civil society voices from across the world during the week of 18-24 May to demand urgency, accountability and more resources in the fight against HIV and AIDS. The severe impact of the AIDS pandemic on families, communities and economies is commonly acknowledged by scientists, the media and politicians the world over. However, more than 25 years later the losses remain stark: AIDS continues to kill almost 6000 people each day and more than 2 out of 3 HIV positive people still lack access to treatment. While women make up an increasing proportion of those living with HIV and bear a greater burden of care, current AIDS responses do not tackle the violation of women’s rights – a key driver of the pandemic.
The WHO Regional Office for Africa is organising this conference in collaboration with UNICEF, UNFPA, UNAIDS, World Bank, African Development Bank and other development partners. Hosted by the government of Burkina Faso, the conference will be the first of its kind to take place in Africa. This year marks the 30th anniversary of the Alma Ata Declaration on Primary Health Care. The conference will address a number of themes: governance of health systems; equity in access to quality health services; resources (human resources, medicine, technology); health financing; health service delivery; multi-sectoral collaboration; community ownership and participation; and decentralisation.
This call is for people to add voice, experience, views, successes and challenges to the policy dialogue addressing the issue of Health Worker Migration and join the Global Dialogue and discuss: How can we best address the challenges raised by health worker migration? What are our shared responsibilities as individuals, countries and as a global community to support the Code of Practice? Chaired by the Honorable Mary Robinson, the Global Discussion starts on 31 of March 2008, at 15.00 GMT.
With funding support from the Canadian Global Health Research Initiative and its ‘Teasdale-Corti’ Research Program, our project goals are to: a. systematically review recent past experiences of comprehensive primary health care from different regions of the world to determine what we know about how it works, what it needs to work and what it has accomplished; b. train up to 20 early career primary health care researchers in undertaking new or augmenting existing CPHC research studies, in teams with ‘research users’ (health policy or program planners) and research mentors (experienced CPHC researchers); c. provide financial support to these research teams to undertake their proposed studies; d. support the building of regional networks of researchers and research users (including civil society groups) to advance comprehensive primary health care as the basis for health system reform in their own countries; e. create a rigorously sound knowledge base on the role of comprehensive primary health care in improving health equity that can be used in the advocacy work of these regional networks. The project is now seeking applications (‘Expressions of Interest’) from research teams committed to developing important new knowledge and action on comprehensive primary health care. These research teams will come from one of four different areas/regions in which are focusing our overall project work: Region 1: India and South Asia; Region 2: Africa; Region 3: Latin America; Region 4: Indigenous/Aboriginal peoples in Canada and Australia. The deadline for expressions of interest is 31 March 2008.
Women’s Dignity promotes citizen engagement to enable all Tanzanians - particularly marginalised girls and women – to realise their basic right to health. We hold a particular commitment to enhancing the rights of girls and women living with obstetric fistula. We support citizens to access and use information to promote their health rights, and seek to ensure policies, programs and services that promote the dignity and rights of the poor. The current and founding executive director will be stepping down on 30 June 2008. Women’s Dignity is looking for a committed, competent, and creative person to lead the organisation. We seek innovation, bold vision, strong management and keen leadership. The organization is in a strong financial position, permitting the new executive director to focus on providing vision and leadership. This is a senior level position requiring an experienced person. WDP offers competitive remuneration in a setting that promotes learning, social justice, team-work and high ethical standards.
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
Website: http://www.equinetafrica.org/newsletter
SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to editor@equinetafrica.org
Please forward this to others.
SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org or send an email to info@equinetafrica.org
This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided.
The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact editor@equinetafrica.org immediately regarding any issues arising.