Two meetings took place in the last month.
On 18-20 April, the Southern Africa Development Community (SADC) held an international conference on poverty and development in Pailles, Mauritius. Background material for the conference prepared by SADC showed the threat posed by critical levels of HIV and AIDS, TB and Malaria to achievement of the Millennium Development Goals (MDGs). Countries were recommended to reprioritise their spending to curb the spread of diseases and other health problems impacting on development, including by meeting commitments to the 2001 Abuja Declaration commitment of 15% of national budgets on public health.
The AU Ministers of Finance and Planning and Economic Development meeting held in Addis Ababa- Ethiopia from 26 March to 2 April also noted with concern the necessity for long-term sustainable financing of and investment in health created by AIDS and other diseases. However, they were publicly silent on the commitment made by African heads of state in 2001 to allocate 15% of their annual national budget to health as a means towards this. Indeed, there are unconfirmed reports from people attending the meeting that some Ministers of Finance argued for the Abuja target adopted by their heads of state in 2001 to be abandoned.
That the region needs to increase its public sector investment in health is not in dispute. Poorer groups continue to have considerably worse health than the better off; economic growth and achieving the Millennium Development Goals (MDGs) in the region is seriously undermined by the prevalence of HIV and AIDS, TB, Malaria and other diseases. Eleven of the sixteen countries in east and southern Africa spend less in their public sectors than the US$34 needed for the most basic interventions for these conditions, let alone the US$60 or more needed for more comprehensive health services. So far, only three countries in the SADC Region have reached the Abuja target, although more are moving in a positive direction. Ten of the sixteen countries in the region would, if they met the Abuja target, increase their public financing to health above the basic level of US$34/capita needed for these basic health programmes.
There is significant potential gain when such increased spending is directed towards primary health care and district services, providing improvements in early detection, access and treatment for disadvantaged groups and in under-served areas. Many of the actions that improve health in poor communities are indeed taken outside the health sector, to improve physical, economic and social environments. However, evidence and experience shows that levering such actions for health across a range of sectors still calls for strong public health leadership, with adequate resources and political support to encourage shared mandates and co-ordinated action for health across all sectors.
The SADC meeting documents made it clear that a public sector led response is vital: Governments have the primary and most important role, responsibility and means for implementing systemic changes and sustaining them in the long run. Government action to reprioritise spending on health and develop sustainable, progressive strategies for financing health care is thus essential to create a basis for complementary strategies and inputs from other sources.
In contrast, diluting or failing to meet commitments to public funding for health undermines the necessary response to a major development challenge with greatest cost to poor households. As the SADC conference on poverty and development was informed, SADC Member States account for 35% of the people living with HIV globally and there are over 5.2 million orphans in the region. The region has the world’s worst TB infection rate and the rate has increased in the last 15 years, while the resources needed to cope with the epidemic have dwindled. New epidemics of multi-drug resistant tuberculosis (MDR-TB) and extreme drug-resistant tuberculosis (XDR-TB) pose grave and rising public health threats, particularly where health resources are limited. There are an estimated 30 million cases of malaria and 400 000 deaths from malaria in the region, with particular risk for children and pregnant women.
Such illness impacts on household income, diverting time and money for caring - sometimes at the expense of food consumption or school enrolment in children - with longer term consequences for poverty and production, especially for agricultural production and food security. Ill health places particular demands on women and children to provide or pay for care. As public funding for health has fallen, the region has also experienced rising charges and out-of-pocket payments for health care. When public services are under-funded or inaccessible and out-of-pocket payments for health increase, this has a particularly impoverishing effect on women, lower income and socially marginalised groups.
So meeting the heads of state commitment in Abuja is important to directly address significant and rising disease burdens; provide the necessary public and health sector leadership to lever other contributions to health; and protect against rising impoverishment and inequality resulting from unaffordable levels of household spending on health care in the lowest income households.
This is clearly not only a matter of increasing resources for health, but of redirecting resources towards greatest health needs. However review of experience in African countries shows that equitable allocation of public sector health care resources is more likely in a situation of increasing resources to health, backed by a policy commitment to equity and explicit mechanisms for achieving reasonable allocation targets.
Not surprisingly therefore, the paper produced by the SADC secretariat for the conference on responses to the economic impact of the three communicable diseases was clear and unequivocal: ‘SADC Member States and governments have committed themselves to many declarations including Abuja 2001 on the three communicable diseases, the Maputo Declaration of 2005 on declaring TB an emergency and UNGASS to name a few. They need to fulfill these obligations and put a mechanism in place to monitor and evaluate them.’
The commitment made by the heads of state in Abuja 2001 towards allocating 15% of their national budgets for health was an important contribution to poverty reduction and equity, and a challenge to international partners to eliminate debt and meet their own commitments to overseas development aid. We would expect a similar level of explicit commitment to the goal from the Ministers of Finance in the region, and more than that delivery on the 15% government funding to health.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. EQUINET calls for “Abuja plus” i.e. 15% government spending to health, increased local and international per capita funding, debt cancellation, abolishing user fees, increasing the share of progressive tax funding, and 50% of government spending to district levels and primary health care. EQUINET work on fair financing in health is available at www.equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
This work was implemented as part of a multi-country programme exploring different dimensions of participatory approaches to people centred health systems in east and southern Africa. The process included participatory workshops with twenty-four health workers to increase their understanding of Community Health Committees (CHCs) and to support the CHCs more effectively in future. Three-day Participatory Reflection and Action (PRA) workshops with representatives from Community Health Committees and key stakeholders, and provided an opportunity for health workers to discuss the roles and mapping of neighbourhoods surrounding the health facilities provided an important opportunity for exploring the similarities and differences in the challenges and resources available to the local communities. The post-test survey showed that the community became aware of the important role and function that committees play but were less satisfied with the functioning of the CHCs based on new understanding from the PRA work, while health workers developed more awareness of the CHCs, their potential and limitations. This was agreed to be the start of a process. While PRA supports communities to know and artculate their needs and actions for these, more needs to be done to ensure sustainability of the process.
The study reviewed existing literature, and held focus group discussions and interviews with key informants to examine the contribution of the AIDS levy in Zimbabwe to national health financing. Two provinces were randomly sampled for the in-depth assessment of spending on AIDS levy. The study revealed that the contribution of the AIDS levy has so far been relatively low and undermined by inflation, with inequities in the allocation of funds by province in relation to HIV prevalence. The provincial and district levels, where most patient care takes place, are severely under-funded. If inflation is controlled for, the study concludes that the AIDS levy is a noble idea but that improvements are needed in the allocation of resources.
3. Equity in Health
Three-quarters of the 68 countries most in need of improving mother and child mortality rates have made little, if any, progress in meeting internationally set goals over the past three years, according to a series of new reports. The Countdown to 2015 for Maternal, Newborn and Child Survival, an international group that monitors these goals, still holds hope that progress can be made quickly in these underachieving nations, according to reports in a special edition of The Lancet. The medical journal looks at the group's efforts in 68 "priority" or "countdown" countries, where 97 percent of the maternal and child under-5 deaths occur worldwide. The group has set goals to reduce child mortality rate by two-thirds and maternal deaths by three-quarters by 2015.
Multidrug-resistant tuberculosis (MDR-TB) has been recorded at the highest rates ever, according to a new report published today. The report presents findings from the largest global survey to date on the scale of drug resistance in tuberculosis. The report also found a link between HIV infection and MDR-TB.
It is increasingly recognised that different axes of social power relations, such as gender and class, are interrelated, not as additive but as intersecting processes. This paper has reviewed existing research on the intersections between gender and class, and their impacts on health status and access to health care. The review suggests that intersecting stratification processes can significantly alter the impacts of any one dimension of inequality taken by itself. Studies confirm that socio-economic status measures cannot fully account for gender inequalities in health. A number of studies show that both gender and class affect the way in which risk factors are translated into health outcomes, but their intersections can be complex. Other studies indicate that responses to unaffordable health care often vary by the gender and class location of sick individuals and their households. They strongly suggest that economic class should not be analysed by itself, and that apparent class differences can be misinterpreted without gender analysis. Insufficient attention to intersectionality in much of the health literature has significant human costs, because those affected most negatively tend to be those who are poorest and most oppressed by gender and other forms of social inequality. The programme and policy costs are also likely to be high in terms of poorly functioning programmes, and ineffective poverty alleviation and social and health policies.
In this paper, authors present the trends in life expectancy in Malawi since independence and offer possible explanations regarding inter-temporal variations. Descriptive analysis reveals that the life expectancy in Malawi has trailed below the Sub Saharan African average. From the 1960s through to the early 1980s life expectancy improved driven mainly by rising incomes and the absence of HIV/AIDS. In the mid 1980s life expectancy declined tremendously and never improved due to the spread of HIV/AIDS, the economic slump that followed the World Bank's Structural Adjustment programmes (SAP) and widespread corruption and poor governance in the era of democracy. At the turn of the new millennium, Malawians were no healthier than their ancestors at the dawn of independence though this improved after 2004. If Malawi is to meet its health Millennium Development Goals by 2015, good governance, improved agricultural performance and an increase in health expenditure should be at the heart of its development policies.
Climate-sensitive impacts on human health are occurring today, attacking the pillars of public health and providing a glimpse of the challenges public health will have to confront on a large scale, WHO Director-General Dr Margaret Chan warned during World Health Day. She said although climate change is a global phenomenon, its consequences will not be evenly distributed. Climate change can affect problems that are already huge, largely concentrated in the developing world, and difficult to control.
This paper reviews theories and empirical findings on inequality and finds evidence for a liberal shift in international development. While the reduction of absolute poverty has become the centre of attention in international development any concern for inequalities and relative poverty has been excluded and(re)distribution of incomes has disappeared from the agenda. However, there are numerous economic and political reasons for which inequality should be seen as a more important and urgent problem, including the violation of social and economic rights due to inequality. These factors combined with the emergence of a global civil society and the dwindling legitimacy of the Bretton Woods institutions may open up a window of opportunity for putting inequality back at the heart of a UN led development cooperation. Authors argue that a 'Global Fund' for globalisation and/or development could play an important role in spreading the concept of world public finances, in proposing global taxes and in organising global redistribution, based on the idea of a global welfare state.
4. Values, Policies and Rights
In Kenya, access to essential medicines is ensured legislatively for HIV, TB and malaria specifically, but delivery is patchy. The situation is improving, but not universally, and there is a continued assault on the IP Act and generic procurements by those who want to profit from selling essential drugs for the poor. Access to medicines is an issue that needs a balance between political will and public involvement/civil society demands. Civil society can demand their rights are realised through campaigns to implement the WTO rules that were designed to protect peoples' access to essential medicines and by stopping the assaults on the procurement of generics, increasing the availability of essential medicines, funding research and development for the medicines we need and abolishing taxes on essential medicines. Providing free essential medicines is the only affordable option for most of the population. This report was presented at the Africa Regional Civil Society meeting on the IGWG on Public Health, Innovation and Access, in Nairobi, Kenya, 28–29 August, 2007.
Participants at the Africa Conference on Sexual Health and Rights affirm that Sexual Rights are an integral and inalienable part of basic Human Rights. This requires that African states be accountable to their citizens for their sexual health and rights. Participants also called for increased accountability across the African continent at all levels – governments, institutions, civil society, communities, families and individuals.
Gendered norms are embedded in social structures, operating to restrict the rights, opportunities, and capabilities, of women and girls, causing significant burdens, discrimination, subordination, and exploitation. This review, developed for the Women and Gender Equity Knowledge Network of the WHO Commission on the Social Determinants of Health, sought to identify the best available research evidence about programmatic interventions, at the level of household and community, that have been effective for changing gender norms to increase the status of women. The focus was on developing countries. Key themes were identified: education of women and girls; economic empowerment of women; violence against women, including female genital mutilation/cutting; and men and boys. A key finding is, that targeting women and girls is a sound investment, but outcomes are dependent on integrated approaches and the protective umbrella of policy and legislative actions.
In this paper, authors investigate the intersections of gender, health and human rights in sites of political exclusion. The paper presents how the recent 'war on terror' is driving health outcomes in refugee and Internally Displaced Persons (IDP) camps. The evidence presented reveals a number of contradictions of refugee and IDP camps, further highlighting the need for a more rights based humanitarianism. The authors conclude that foregrounding states of exception, as a way of understanding current gender dynamics in the social determinants of health, is both epidemiologically necessary and conceptually useful. In these sites of exclusion, the indispensability of a human rights approach to gender and health equity issues is revealed most directly.
This presentation given at the second regional meeting of the African Civil Society Coalition on the Intergovernmental Working Group (IGWG) on Public Health, Innovation and Intellectual Property in Arusha, Tanzania, 3-4 April 2008 provides an introduction to the workings of the IGWG and gives international context for its operations. Drug development and application processes are explained and much of the report is devoted to an evaluation of the IGWG's fixed-dose artsunate-based combination therapy (FACT) project for the treatment of malaria.
5. Health equity in economic and trade policies
Demanding assurance that their countries would be better off agreeing to enter Economic Partnership Agreements (EPAs) with the European Union (EU), African finance and trade ministers have insisted that the development dimension must be comprehensively addressed in the deals. In a declaration on the negotiations, the ministers also urged the negotiators to ensure that EPAs take into consideration the coherence between trade and development dimensions as well as Africa's regional integration efforts. After a one-day joint meeting, convened by the African Union Commission (AUC) to give political guidance on pressing issues in the areas of trade and development in relation to the EPAs, the ministers noted that the interim deals with the European Commission (EC) were contentious on a number of issues, including the definition of substantially all trade, transitional periods, export taxes, free circulation of goods, national treatment, bilateral safeguards and the non-exclusion clause.
African countries have always struggled to participate fully in the World Trade Organisation (WTO) and to influence its decisions. In addition to under-representation at WTO headquarters, the complexity of WTO bodies, rules and procedures weakens inputs. This book provides guidance in understanding how international trade institutions and agreements 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 world trade. Organised around descriptive and factual texts, this work contains many definitions and is illustrated by concrete experiences that facilitate reading.
The High Level Technical Meeting in Cape Town, South Africa, 7-8 April, 2008 undertook a comprehensive stock taking of EPAs that have been concluded in order to provide countries with an objective and accurate assessment of the content, character and implications of the various agreements that will help guide and inform their policy choices. For example, specific studies on particular issues identified useful to assist in the negotiations should be conducted and the ACP Secretariat/Commonwealth Secretariat should assist in organising sensitisation seminars for government officials and Parliamentarians and other stakeholders on EPAs and related issues.
Intellectual property rights issues on the table in the newly invigorated World Trade Organization negotiations are at risk if remaining deep differences cannot be further narrowed in the coming weeks, WTO Director General Pascal Lamy said. A significant majority of WTO members support either the proposed TRIPS amendment, or the Geographic Indications extension, and the negotiations on each have been linked by proponents in the consultations. But a smaller number of members do not agree to negotiate on the CBD amendment or GI extension, though they do not exclude further discussion, according to Lamy.
The World Intellectual Property Organization is seen as in a state of tumult these days, as the global body searches for a new director general and tries to grapple with issues such as implementing a Development Agenda and further harmonising global patent regimes. And some industry observers think it is causing some to lose trust in the organisation.
After an innovative partnership between a non-governmental group and a pharmaceutical company led to a new cheap non-patented drug against malaria being available in Africa in 2007, the model is being implemented again with another new non-patented anti-malarial drug being delivered to South American patients. Drug research and development being carried out under public funding is a new model that should lead the way, Ann-Marie Sevcsik, DNDi scientific communications manager, told Intellectual Property Watch. “Research and development should be ‘needs-driven’ instead of profit-driven, and not only for neglected diseases but for neglected patients, like cancer patients in the developing world,” she said.
By the end of 2007, only eighteen African states (including most non-LDCs and some LDCs) had initialled interim EPAs, as had two Pacific non-LDCs (Fiji and Papua New Guinea), while Caribbean countries went further and approved full EPAs. What have they agreed to? What are the main implementation challenges, some of which will require support from Europe? And for those that remain committed to this process, what are the options for the completion of negotiations towards full EPAs? The Overseas Development Institute (ODI) and the European Centre for Development Policy Management (ECDPM) study attempts to analyse these questions as comprehensively as possible, with a focus on Africa. This article summarises some of the main findings.
Since 2000, the Uganda Law Reform Commission has been spearheading the process of reforming Uganda’s patent legislation. The reform is taking place in the context of the Doha Development Agenda, a process for continued negotiations on areas of concern within the WTO agreements raised by developing countries during the Fourth Ministerial Conference in Doha, Qatar in November 2001. Although the country's draft bill has been improved in a number of aspects, there is still need for improvement on the drafting language to make use of the flexibilities in the widest allowable sense and capture the new thinking regarding these flexibilities.
Any renegotiation of the economic partnership agreements (EPAs) already initialled with the countries of Africa, the Caribbean and the Pacific (ACP) would be a disaster, Trade Commissioner Peter Mandelson told members of the EP International Trade Committee on Thursday. Referring to recurrent criticisms of the EPAs, Mr Mandelson ruled out "any suggestion of renegotiating the agreements already initialled". Any renegotiation would constitute "a new threat of legal uncertainty to the agreements but would also be a disaster for the ACP countries", according to Mr Mandelson, who restated his goal of concluding "full EPAs with comprehensive regional coverage" in the six geographical regions.
This paper presented at the second regional meeting of the Africal Civil Society Coalition on the Intergovenmental Working Group on Public Health, Innovation and Intellectual Property Rights in Arusha, Tanzania, 3-4 April 2008 highlights the process in developing AFRO's approach to the negotiations, the common AFRO position(s), and achievements and challenges so far. A number of concerns have been incorporated in the Draft Strategy and Plan of Action progress report, while some interests are not yet realised because either the respective issues have not yet been negotiated or no consensus has yet been reached on them.
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6. Poverty and health
COMESA's goal is the establishment of a free trade area, a customs union, a common market and ultimately an economic union. COMESA is home to 10 of the poorest countries in the world - Angola, Burundi, Ethiopia, Malawi, Mozambique, Rwanda, Somalia, Sudan, Zaire and Zambia. This paper examines the impact of COMESA on the poor. The report finds that while COMESA has liberalised trade in goods and services generally, there is now an urgent need to liberalise intra-regional trade in services and improve relations among its members. Conflicts in COMESA are unsustainable and strong
implementation mechanisms are needed to address non-tariff barriers and other trade restrictions within the region, with decisions on how transfer of sovereignty in some areas of trade policy to regional institutions is done in relation to SADC and COMESA.
The region as a whole is not on track to meet the MDG targets owing to, among others, increased prevalence of communicable diseases. In this paper, authors discuss the Economic impact of the three communicable diseases: HIV and AIDS, TB and Malaria and demonstrate that these diseases negatively affect economic growth. The paper is based on literature review of studies done within and outside the SADC region on the impact of the three communicable diseases.
This book analyses interactions between food insecurity, vulnerability and the right to food. The significance of a human rights approach, and the way in which it translates to gender considerations, with links to the HIV/AIDS pandemic, agricultural productivity and the environment, adds a new dimension to the problem of world hunger. By exploring these approaches to hunger this volume shifts away from research on macro food availability to more composite dimensions cutting across economics, sociology, law and politics. It includes a chapter on Food Security in the SADC Region: An Assessment of National Trade Strategy in the Context of the 2001-03 Food Crisis by A.Charman & J.Hodge and on Gender, HIV/AIDS and Rural Livelihoods: Micro-Level Investigations in Three African Countries by J.Curry, E.Wiegers, A.Garbero, S.Stokes & J.Hourihan.
The current global food crisis will impact most in the world’s poorest countries civil society leaders said in Accra on the opening day of UN Conference on Trade and Development (UNCTAD). The meeting, organised with the collaboration of UNCTAD and the UN’s Office of the High Representative for LDCs, LLDCs and SIDS (UN-OHRILLS), was addressing the continued vulnerability of LDCs. Hosted by Ghana, the UNCTAD XII conference entitled “Making Globalisation Work for Development” is seeking to identify opportunities of globalisation for developing countries. However as the civil society meeting heard current international policies are not addressing the systemic problems facing LDCs.
This special issue explores how the forces of globalisation influence poverty; describes and discusses the main transmission channels and mechanisms; and analyses the impact of globalisation on Africa through six case studies.
Microfinance has been recognised, globally, as a viable and sustainable tool for poverty reduction and economic development through improving income generating activities and employment creation. Despite well documented evidence of the positive impact of promoting access to finance to under-served segments of the community, many poor people in the Africa, particularly in Southern African Development Community (SADC), still remain excluded from the mainstream financial system. Microfinance programmes are reported to stimulate the growth of the micro-enterprises and the SME sectors, assist in the formalization of the informal sector and integrate that sector into the mainstream economy, thus contributing to socio-economic development and to poverty reduction.
Poverty and Social Impact Analysis (PSIA) and Poverty Impact Assessment (PIA) are recently developed tools for analysing the distributional impact of policies, programmes and projects on the well-being of the population, with particular focus on the poor and vulnerable. Both approaches provide a comprehensive framework for analysis while drawing on a wide range of well-established approaches and tools covering economic, social, political and institutional issues. The International Poverty Centre (IPC) is administering a joint United Nations Development Programme (UNDP) / World Bank Project on PSIA. The overall objective is to promote capacities in developing countries for analytical work on the impact of national policies and to use these results to influence poverty reduction strategies. This involves adjusting policy design in light of the impact of policies on poor women and men, and providing evidence to inform national policy dialogue.
This article analyses the effectiveness of the investment that the Rockefeller Foundation and the Bill & Melinda Gates Foundation recently announced - a joint ‘Alliance for a Green Revolution in Africa’ (AGRA). The authors argue that, based on the first Green Revolution experience, this initiative will not succeed because: 1. The Green Revolution actually deepens the divide between rich and poor farmers; 2. Over time, Green Revolution technologies degrade tropical agro-ecosystems and increase environmental risk; 3. The Green Revolution leads to the loss of agro-biodiversity; 4. Hunger is not primarily due to a lack of food, but rather because the hungry are too poor to buy the food that is available; 5. Without addressing structural inequities in the market and political systems, approaches relying on high input technologies fail; 6. The private sector alone will not solve the problems; 7. Genetic engineering (GE) will make Sub-Saharan smallholder systems more environmentally vulnerable; 8. GE crops into smallholder agriculture will likely lead to farmer indebtedness; 9. The assertion that “There Is No Alternative” (TINA) ignores the many successful agro-ecological and non-corporate approaches to agricultural development; 10. AGRA’s “alliance” does not allow peasant farmers to be the principal actors in agricultural improvement. The authors conclude that if the Gates and Rockefeller Foundations want to end hunger and poverty in rural Africa, then they should invest in the service of the struggle by peasant and farmer organisations and their allies to truly achieve food sovereignty.
Zimbabwe will be the first country in Southern Africa to adopt a new food security analysis tool, developed in Somalia in 2004. The Integrated Food Security Phase Classification Framework (IPC) categorises the severity of a situation using a five-phase scale ranging from 'generally food secure' to 'famine/humanitarian catastrophe', based on comprehensive data on the impact of a crisis on food security and nutrition.
7. Equitable health services
The authors investigated the emotional and behavioral problems of orphans in Rakai District, Uganda and suggested interventions. Most lived in big poor families with few resources, faced stigma and were frequently relocated. Community resources were inadequate. Compared to non-orphans, more orphans exhibited common emotional and behavioral problems but no major psychiatric disorders. Orphans were more likely to be emotionally needy, insecure, poor, exploited, abused or neglected. Most lived in poverty with elderly widowed female caretakers. But they showed high resilience in coping. To comprehensively address these problems, we recommend setting up a National Policy and Support Services for Orphans and Other Vulnerable Children and their families, a National Child Protection Agency for all Children, Child Guidance Counselors in those schools with many orphans and lastly social skills training for all children.
The re-admission rate and the number of preventable re-admissions in a secondary-level South African hospital were measured to identify factors predictive of re-admission. The admission register for the medical wards at Cecilia Makiwane Hospital (CMH) was used to identify re-admitted patients, whose folders were then reviewed. A comparison group of patients who were not re-admitted was randomly generated from the same register. One in twelve general medical patients was readmitted. Chronic diseases and inadequate patient education and discharge planning accounted for the largest group of re-admissions in older patients. Re-admission of HIV/AIDS patients has generated a second peak in younger individuals, and the impact of the antiretroviral roll-out on admission rates warrants further scrutiny.
This report on global tuberculosis (TB) control compiles data from over 200 countries to monitor the scale and direction of TB epidemics, implementation and the impact of the Stop TB Strategy. Whilst there has been progress in HIV testing among TB patients, implementation of interventions to reduce the burden of TB in HIV-positive people is far below the targets set in the Global plan in 2006. Overall, there are several signs that global progress in TB control is slowing and that there are parts of the world where much more needs to be done to achieve the global targets that have been set. The report recommends that renewed effort to increase the rate of progress in global TB control in line with the expectations of the Global Plan, backed up by intensified resource mobilisation from domestic and international donors, is required.
Malaria over-diagnosis in Africa is widespread and costly both financially and in terms of morbidity and mortality from missed diagnoses. An understanding of the reasons behind malaria over-diagnosis is urgently needed to inform strategies for better targeting of antimalarials. In an ethnographic study of clinical practice in two hospitals in Tanzania, 2,082 patient consultations with 34 clinicians were observed over a period of three months at each hospital. Clinicians were found to follow mindlines as well as or rather than guidelines, which incorporated multiple social influences operating in the immediate and the wider context of decision making. Interventions to move mindlines closer to guidelines need to take the variety of social influences into account.
This World Health Organisation review examines the implementation of primary health care (PHC) in Africa and identifies the strategic interventions required to cope with the new challenges facing the health systems in the 21st century. The review addresses PHC policy formation and implementation, the resources that are available for PHC implementation, monitoring and review. PHC policy formation had been well articulated in the national health policies by most countries, however, the extent to which PHC policies encompassed equity, community participation, inter-sectoral collaboration and affordability is still questionable. Factors delaying PHC implementation include weak structures, inadequate attention to PHC principles, inadequate resource allocation and inadequate political will. The key recommendations of the review include to: harmonise health sector reforms with PHC to ensure that initiatives promote equity and quality in health services; improve the fairness of financing policies and strategies and service coverage for the poor; support countries to address their particular human resource needs through clear articulation of human resources policies, plans, development and strengthening of national management systems and employment policies; support countries to identify and put in place mechanisms for attracting and retaining health personnel.
The aim of this research was to understand key issues in the functioning of two different primary care clinics serving the same community, in order to learn more about clinic management. Data were collected in a government and an NGO clinic in the North West province of South Africa. Key findings included: (i) there are attitudinal differences between the staff at the two clinics; (ii) the patients appreciate the services of both clinics, though they view them differently; (iii) clinic A provides a wider range of services to more people more often; (iv) clinic B presents a picture of quality of care, related to the environment and approach of staff; (v) waiting time is not as important as how patients are treated; (vi) medications are a crucial factor, in the minds of staff and patients; and (vii) a supportive, empowering organisational culture is needed to encourage staff to deliver better care to their patients. The management of the clinic is part of this culture. A respectful and caring approach to patients, and an organisational culture which supports and enables staff, can achieve much of this without any additional resources.
Despite the need for oral health morbidity surveys to aid in reviewing of the oral health services, dental data of Ugandan children is scanty. This paper set out to describe the magnitude and distribution of selected oral health conditions among primary school children in Mbarara, Uganda. The oral hygiene of school children was poor, with high plaque prevalence demonstrating a lack of established oral hygiene practices. A comprehensive community-focused oral health care intervention that includes oral health education in homes and the strengthening of school health programme is needed to improve the oral health status of children in Mbarara.
This World Health Organisation review examines the implementation of primary health care (PHC) in Africa and identifies strategic interventions required to cope with the new challenges facing the health systems in the 21st century. The review addresses PHC policy formation and implementation, the resources that are available for PHC implementation, monitoring and review. The review finds that PHC policy formation had been well articulated in the national health policies by most countries, however, the extent to which PHC policies encompassed equity, community participation, inter-sectoral collaboration and affordability is still questionable. Factors delaying PHC implementation include weak structures, inadequate attention to PHC principles, inadequate resource allocation and inadequate political will.
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.
The US House of Representatives passed HR5501, the US Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2008 on April 2 by a vote of 308-116. Amongst other things, the bill: authorises US$50billion for AIDS, TB, and malaria programs including US$9billion for TB and malaria; links AIDS, TB, and malaria programs to broader health and development programs; formalises activities currently operating under the President’s Malaria Initiative which includes a five-year malaria strategy and a malaria coordinator; calls for enhanced coordination within US government agencies in planning and implementing all three disease areas and with other global health and development programs.
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8. Human Resources
At the first Global Forum on Human Resources for Health in Kampala, Uganda, delegates endorsed a Global Agenda for Action on the alarming imbalances in the availability and distribution of health workers worldwide. One component of the Agenda was a pledge to "accelerate negotiations for a code of practice on the international recruitment of health workers". The first step was taken on March 31 with the launch of a 3-week online global dialogue convened by the Health Worker Migration Policy Initiative. The global dialogue provided a unique opportunity for anyone affected by the vast complexities of health-worker migration, in whatever capacity, to share experiences and knowledge on the realities of migration, on effective strategies to retain health workers where they are needed most, and on what the key principles of a global code of practice should be. The paper questions whether another code of practice really required.
Many developing countries suffer from critical shortages of trained health workers, but Malawi’s shortage is severe even by African standards. Measures to recruit and retain more staff are urgently needed.This paper reports on the employment preferences of public sector registered nurses in Malawi to help design incentives to encourage them to remain in Malawi's public health sector. Improved pay was the single most important attribute identified that might improve job satisfaction, followed by opportunities for further education and the provision of basic housing. Improvements in the quality of housing provided would have little impact on how nurses value their employment. Establishing the relationship between pay increases and retention of registered nurses would require additional research.
The impact of intermittent preventive treatment (IPTp) on malaria in pregnancy is well known. However, in countries where this policy is implemented, poor access and low compliance have been widely reported. Novel approaches are needed to deliver this intervention. This paper assesses whether or not traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilisers can administer IPTp with sulphadoxine–pyrimethamine (SP) to pregnant women, reach those at greatest risk of malaria, and increase access and compliance with IPTp. The report found that the community approach was effective for the delivery of IPTp, although women still accessed and benefited from malaria treatment and other services at health units. However, the costs for accessing malaria treatment and other services are high and could be a limiting factor.
This review examines the experiences of nurses, community health workers, and home carers in health systems from a gender analysis. With respect to nursing, current discussions around delegation take place over layers of historical struggle that mark the evolution of nursing as a profession. Female community health workers also struggle to be recognized as skilled workers, in addition to defending at a personal level the legitimacy of their work, as it transgresses traditional norms proscribing morality and the place of women in society, at times with violent consequences. The review concludes by exploring the characteristics of, and challenges faced by, home carers, who fail to be recognized as workers at all. A key finding is that these mainly female frontline health workers compensate for the shortcomings of health systems through individual adjustments, at times to the detriment of their own health and livelihoods. So long as these shortcomings remain as private, individual concerns of women, rather than the collective responsibility of gender, requiring public acknowledgement and resolution, health systems will continue to function in a skewed manner, serving to replicate inequalities in the health labour force and in society more broadly.
A cross-sectional voluntary, anonymous, unlinked survey including an oral fluid or blood sample and a brief demographic questionnaire where undertaken in two public hospitals in Gauteng, South Africa to determine the prevalence of HIV infection and the extent of disease progression based on CD4 count in a public health system workforce in southern Africa. The overall prevalence of HIV was 11.5%. By occupation, prevalence was highest among student nurses (13.8%) and nurses (13.7%). The highest prevalence by age was in the 25-34-year group (15.9%). Nineteen per cent of HIV-positive participants who provided blood samples had CD4 counts less than or equal to 200 cells/μl, 28% had counts 201-350 cells/μl, 18% had counts 351-500 cells/μl, and 35% had counts above 500 cells/μl. One out of 7 nurses and nursing students in this public sector workforce was HIV-positive. A high proportion of health care workers had CD4 counts below 350 cells/μl, and many were already eligible for antiretroviral therapy under South African treatment guidelines. Given the short supply of nurses in South Africa, knowledge of prevalence in this workforce and provision of effective AIDS treatment are crucial for meeting future staffing needs.
Who should assist women in childbirth, what should these attendants do and not do under various circumstances, and where should births take place? Policies regarding these questions have been debated for hundreds of years. WHO’s position on where and with whom women should deliver has evolved from emphasis on training of traditional birth attendants (TBAs) in developing countries in the late 1950s and 1960s, to a recommendation that TBAs work with the health-care system, to a recommendation that they be integrated into the health system via training, supervision and technical support, to today’s position of promoting professionally skilled attendance at all births. The facts that a) this position was adopted in 1997 and that it took an additional two years to specify the criteria required to be a “skilled attendant”, and b) that the policy sidesteps the issue of where births should take place, suggests that substantial internal debate swirled around this stance, as well. Although the WHO skilled attendance at birth policy remains today, it has now been incorporated into a continuum of maternal and child health care policy, resulting from the formation of the Partnership for Maternal, Newborn and Child Health in 2005.
The shortage of qualified health professionals is a major obstacle to achieving better health outcomes in many parts of the world, particularly in Africa. The role of health science universities in addressing this shortage is to provide quality education and continuing professional development opportunities for the healthcare workforce. Academic institutions in Africa, however, are also short of faculty and especially under-resourced. We describe the initial phase of an institutional partnership between the Muhimbili University of Health and Allied Sciences (MUHAS) and the University of California San Francisco (UCSF) centred on promoting medical education at MUHAS. The challenges facing the development of the partnership include the need: (1) for new funding mechanisms to provide long-term support for institutional partnerships, and (2) for institutional change at UCSF and MUHAS to recognize and support faculty activities that are important to the partnership. The growing interest in global health worldwide offers opportunities to explore new academic partnerships. It is important that their development and implementation be documented and evaluated as well as for lessons to be shared.
9. Public-Private Mix
Using market mechanisms in the provision of health services and seeing health care as a private good are approaches that have featured prominently in health sector reforms across the world. The UNRISD research on global and local experiences of health care commercialization challenges this framework. It calls for reclaiming public policies that promote the purposes that health systems are set up to serve: population health and the provision of care for all according to need.
This report - presented at the African Civil Society Meeting of the Intergovernmental Working Group on Intellectual Property, Innovation and Health in Nairobi, Kenya, 28-29 August 2007 - found that there are over 30 registered local manufacturers in Kenya and at least two others under construction (foreign investments). It also analysed seven private-private partnership (PPP) projects (six in Kenya & one in Tanzania). The first PPP project passed its first inspection in August 2007 and the others are due for inspection by the end of the project. The main outcome of the report was that intellectual property rights do not stimulate research and development for medicines for diseases prevalent in developing countries simply because the market in poor countries is considered to be too small or too uncertain.
10. Resource allocation and health financing
In 2001, Kenya was one of nine countries to receive financial backing to introduce the Haemophilus influenzae type b (Hib) vaccine. How cost-effective has it been? Recently the Kenyan government agreed to co-finance the costs of the vaccine from 2006 to 2011, gradually increasing its contributions. The study concluded that Hib vaccine is a highly cost-effective intervention in Kenya. Although the level of disease is relatively low, the investment required for disease prevention is also low.
Kenya has had a history of health financing policy changes since its independence in 1963. Recently, significant preparatory work was done on a new Social Health Insurance Law that, if accepted, would lead to universal health coverage in Kenya after a transition period. Questions of economic feasibility and political acceptability continue to be discussed, with stakeholders voicing concerns on design features of the new proposal submitted to the Kenyan parliament in 2004. For economic, social, political and organisational reasons a transition period will be necessary, which is likely to last more than a decade. However, important objectives such as access to health care and avoiding impoverishment due to direct health care payments should be recognised from the start so that steady progress towards effective universal coverage can be planned and achieved.
This article examines the role of microfinance and member-owned institutions (MOI) such as local savings and credit associations both for the provision of reparations and for post-conflict and post-disaster reconstruction. It finds that microfinance could play a crucial role in reconstruction. However, microfinance is limited by: the lack of potential clients with business skills and their lack of assets; the breakdown of existing markets; physical insecurity. In the special case of human rights abuses, microfinance institutions might be instrumental as they: stregthen the self-financing capacity of the recipients of reparation payments; offer credit for investment and working capital to small and micro entrepreneurs; attract external finance. Member-owned organisations are particularly useful because, amongst other things, they can contribute to the establishment or reconstruction of civil institutions.
This paper focuses on the efforts to increase development aid. What were the decisions and promises made following the adoption of the Millennium Development Goals? What pledges and commitments did the traditional donor agencies and the developed countries make? What are the achievements? Did they deliver? The paper finds that the traditional donor countries – the G8 and the OECD countries - have delivered far less than promised and expected. The target of doubling aid flows to Africa in 2010 compared to 2004 is unlikely to be achieved. There have been significant increases in aid to Africa but most of the additional aid is provided for debt relief operations with only modest increases in aid for development programmes. In Southern Africa all increase is tied to debt relief operations (mainly for the DR Congo) with no additional aid provided for development programmes. Although not much additional development aid is forthcoming through these channels; it may have helped to shift priorities to accelerate achievement of some MDGs, such as child health. The emergence of China and other emerging powers in the south as development actors in Africa is of major significance. It creates both new opportunities and new challenges for development and poverty reduction. These countries are not primarily providers of development aid, but they are important in assisting development as investors, traders and providers of support for infrastructure development – and in potentially increasing the bargaining power of African states.
Mozambique is referred to as being a success story after seventeen years of civil war and economic and social decline. The country is highly dependent on external aid. Long before the Paris Declaration on Aid Effectiveness, the Government of Mozambique (GoM) and a group of donors made efforts to coordinate and harmonise external aid. Therefore, it is interesting to study the evolution of external aid mechanisms to the country. The general objective of the research is to contribute to the agenda, discussion and results of the Ghana High Level Forum on aid effectiveness, reporting on progress and concerns regarding the implementation of the Paris Declaration. In the specific case of Mozambique, the research aims to examine critically the aid system and the mplications of the Paris Declaration, especially concerning ownership and accountability in the external aid system.
The Paris Declaration on Aid Effectiveness may have the effect of circumscribing national sovereignty and country autonomy over development policies contrary to its stated principles of country ownership and mutual accountability, research has shown. Two recent studies have highlighted the propensity of new modalities of aid and aid harmonisation processes under the Paris Declaration framework to increase rather than reduce donor interventions in aid recipient countries and exacerbating the imbalances of power between donor and recipient countries.
11. Equity and HIV/AIDS
Few sub-Saharan African countries have substantial analyses of the rural and agricultural situations in their Poverty Reduction Strategy Papers (PRSPs) and the link between agriculture and HIV and AIDS is therefore missed. Rural poverty is at the root of risky behavior (sexual services for food, cash or other resources), which can often lead to an HIV infection, hence the rate of HIV transmission can only be effectively reduced by reducing rural poverty. The report recommends improvements in agriculture, food supply, local social security networks (which provide information and behavioural advice) and access to assets that can be mobilised as alternatives to transactional sex. Gender issues also need to be addressed.
By 31 December 2006, Malawi had enrolled 82 000 patients in its free national antiretroviral treatment (ART) programme. Each quarter, data from all ART clinics are aggregated for national reporting on ART scale-up. This information is essential to monitoring site performance, guiding national planning and supporting sustained funding. Despite increasing reliance on sites to aggregate data, the completeness and accuracy of sites’ reports was unknown. The authors therefore conducted an operational study during regular supervisory visits to assess the quality of data in the site reports. Specific objectives were to: i) determine the completeness and accuracy of key case registration and outcome data compiled by ART clinics, ii) compare national data summarized from site reports versus supervision reports, and iii) analyse characteristics associated with sites’ capacity to compile quality data.
This paper describes the experience of Zimbabwe in establishing a baseline for its National Action Plan for Orphans and Other Vulnerable Children (NAP for OVC) using the 10 core indicators developed by the UNAIDS Global Monitoring and Evaluation Reference Group in 2004. Through a population-based household survey in rural and urban high-density areas and the OVC policy and planning effort index assessment tool, a baseline was established. The survey found that 43.6% of children under 18 years were orphaned or made vulnerable by HIV/AIDS. Half of all households with children care for one or more OVC. While the large majority of OVC continued to be cared for by the extended family, its capacity to care for these children appeared to be under pressure. OVC were less likely to have their basic minimum material needs met, more likely to be underweight, less likely to be taken to an appropriate health provider when sick and less likely to attend school. Medical support to households with OVC was found to be relatively high (26%). Other support, such as psychosocial support (2%) and school assistance (12%), was lower. The OVC Effort Index assessment indicates that serious efforts are being made. The increase in the effort index between 2001 and 2004 in the areas of consultative efforts, planning and coordinating mechanisms reflects the strengthened commitment. Monitoring and evaluation and legislative review are the weakest areas of the OVC response. The findings of the baseline exercise point to the need for continued and additional efforts and resources to implement the NAP for OVC, the priorities of which were confirmed by the survey as critical to improve the welfare of the OVC in Zimbabwe.
The diagnosis and management of childhood tuberculosis (TB) are major challenges in countries such as Malawi with high incidence of TB and human immunodeficiency virus (HIV) infection. Diagnosis of TB in children often relies only on clinical features but clinical overlap with the presentation of HIV and other HIV-related lung disease is common. The tuberculin skin test (TST), the standard marker of M. tuberculosis infection in immune competent children, has poor sensitivity in HIV-infected children and is not usually available in Malawi. HIV test should be routine in children with suspected TB as it improves clinical management. HIV-infected children are at increased risk of developing active disease following TB exposure which justifies the use of isoniazid preventive therapy (IPT) once active disease has been excluded but this is difficult to implement and appropriate duration of IPT is unknown. HIV-infected children with active TB experience higher mortality and relapse rates on standard TB treatment compared to HIV-uninfected children, highlighting the need for further research to define optimal treatment regimens. HIV-infected children should also receive appropriate supportive care including co-trimoxazole prophylaxis and anti-retroviral treatment (ART) if indicated. There are concerns about concurrent use of some anti-TB drugs such as rifampicin with some ARTs.
In 2004, South Africa had one of the highest rates of HIV infection in the world and the province of KwaZulu-Natal (KZN) reported the peak of 40.7% positivity among the antenatal population. The purpose of this study was to identify measures to improve the quality of an HIV prevention program targeted at reducing the rate of mother-to-child transmission of HIV infection (MTCT). A cross-sectional observational (non-experimental) study was conducted from Empangeni hospital (i) using antenatal clinic registers between May 2002 and April 2003 and (ii) applied a questionnaire survey to a randomly selected sample of 306 HIV infected women who delivered between April and June 2004. The results showed that among 3774 antenatal attendees, 2528 (67%) accepted pre-test counselling and 2390 (63%) HIV testing. Majority (95%) of those who had (2528) pre-test counselling accepted HIV testing, post test counselling and test results. The prevalence of HIV infection was 41% (980) (95% CI, 39%-43%). Among them (980 HIV positive), 73% (716) received nevirapine during the antenatal period yielding an overall antenatal nevirapine prophylaxis (uptake) rate of 46% (based on an estimate of 41% HIV prevalence rate for total antenatal population of 3774 during the study period). Between April to June 2004, 2393 women delivered at Empangeni hospital of which 39% (933) were HIV positive. The coverage of pretest counselling for HIV testing (67%) and nevirapine use (46%) was low. We found in the questionnaire survey that the participating women had adequate knowledge and compliance on the use of nevirapine. Strategies are needed to improve program uptake and effectiveness of the prevention of mother-to-child transmission of HIV infection (PMTCT) program in rural South Africa.
Ten per cent of individuals infected with TB develop the active disease but this is greatly increased in those whose immune systems have been weakened by HIV. This report from the Forum for Collaborative HIV Research highlights the difficulty in managing the co-epidemic of HIV and TB that is rapidly spreading in Sub-Saharan Africa. The report concludes that strategies for dealing with TB and HIV currently exist in isolation, often reinforced by vertical programme financing. Efforts must be made to integrate these disease treatment programmes that will involve stakeholders working together within an evidence-based collaborative framework.
This book examines the global governance of the AIDS epidemic, interrogating the role of this international system and global discourse on interventions. The geographical focus is Sub-Saharan Africa since the region has been at the forefront of these interventions. There is a need to understand the relationship between the international political environment and the impact of resulting policies on HIV and AIDS in the context of people's lives. There is a certain disjuncture between this governance structures and the way people experience the disease in their everyday lives. Although the structure allows people to emerge as policy relevant target groups and beneficiaries, the articulation of needs and design of policy interventions tends to reflect international priorities rather than people's thinking on the problem and the nature of the system does not allow interventions to be far reaching and sustainable.
This review of progress made on a three-year tuberculosis TB/HIV plan implemented in Malawi between 2003 and 2005 found that barriers to testing TB patients for HIV include: irregular supplies of HIV-testing reagents, staff forgetting to refer patients or patients themselves not undergoing HIV testing and counselling after being registered and placed on anti-TB treatment. The authors recommend that ways to improve HIV-testing uptake need to be found, including the integration of HIV testing with the TB registration process itself. The monitoring systems for HIV and TB need to explicitly include the relevant parameters, for example, TB monitoring tools which include data on numbers of TB patients who have been tested for HIV, who are HIV-positive, and who have started antiretroviral therapy.
Currently South Africa does not have national HIV incidence data based on laboratory testing of blood specimens. The 2005 South African national HIV household survey was analysed to generate national incidence estimates stratified by age, sex, race, province and locality type, to compare the HIV incidence and HIV prevalence profiles by sex, and to examine the relationship between HIV prevalence, HIV incidence and associated risk factors. HIV incidence in the study population aged 2 years and older was 1.4% per year, with 571 000 new HIV infections estimated for 2005. An HIV incidence rate of 2.4% was recorded for the age group 15-49 years. The incidence of HIV among females peaked in the 20-29-year age group at 5.6%, more than six times the incidence found in 20-29-year-old males (0.9%). Among youth aged 15-24 years, females account for 90% of the recent HIV infections. Non-condom use among youth, current pregnancy and widowhood were the socio-behavioural factors associated with the highest HIV incidence rates. The HIV incidence estimates reflect the underlying transmission dynamics that are currently at work in South Africa. The findings suggest that the current prevention campaigns are not having the desired impact, particularly among young women.
In settings of armed conflict, traditional HIV prevention programmes that promote risk avoidance via abstinence and fidelity and risk reduction via condom use and needle exchange are not viable. In such contexts, HIV risk depends less on personal choice than on exposure to physical, emotional and structural violence. War in northern Uganda has created three realities (internally displaced people's camps, night commuters and child abductions) which increase vulnerability to HIV transmission. Based upon this analysis of northern Uganda, we offer a conceptual framework for HIV transmission in conflict settings that recognizes the importance of local and global context in creating vulnerability to HIV infection. This framework is then used to delineate strategies for HIV prevention in northern Uganda, namely the provision of a safe physical environment and access to education, medical and psychological support, and the promotion of conflict resolution strategies and human rights law.
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12. Governance and participation in health
The elaboration of Poverty Reduction Strategies has seen a promising amount of stakeholder participation in many PRS countries, even if considerable quality problems are recognisable, such as exclusion of marginalised groups, speed and depth and the ad hoc nature of participation events as well as macroeconomic and structural policies being off-limits. Most countries have started implementing their PRSP,with participation dwindling instead of being institutionalised. Some observers speak of a 'participation gap'. The situation seems to be slightly more promising for the issue of participation in monitoring and evaluation of PRS, as in many countries independent civil society monitoring or participatory monitoring arrangements are planned, although mostly not yet operational. Stakeholder participation in the revision process has been occurring in a number of countries, but not much is known about the way this is done. For most of these issues a systematic review of experience is not available at this stage. Work is planned to increase the current understanding of the status, practice and challenges of participation in PRS implementation (including monitoring, evaluation, revisions, policy reforms, and institutionalisation) and to make conceptual as well as 'good practice' contributions to the current discussion.
Accountability refers to the processes by which those with power in the health sector engage with, and are answerable to, those who make demands on it, and enforce disciplinary action on those in the health sector who do not perform effectively. This paper reviews the practice of accountability to citizens on gender and health, assesses gaps, and recommends strategies. Four kinds of accountability mechanisms have been used by citizens to press for accountability on gender and health. These include international human rights instruments, legislation, governance structures, and other tools, some of which are relevant to all public sector services, some to the health sector alone, some to gender issues alone, and some to gender-specific health concerns of women. However, there are few instances wherein private health sector and donors have been held accountable. Rarely have accountability processes reduced gender inequalities in health, or addressed 'low priority' gender-specific health needs of women. Accountability with respect to implementation and to marginalized groups has remained weak. This paper recommends that: (1) the four kinds of accountability mechanisms be extended to the private health sector and donors; (2) health accountability mechanisms be engendered, and gender accountability mechanisms be made health-specific; (3) resources be earmarked to enable government to respond to gender-specific health demands; (4) mechanisms for enforcement of such policies be improved; and (5) democratic spaces and participation of marginalised groups be strengthened.
13. Monitoring equity and research policy
NGO-based and rigorously monitored development programmes are bringing about important and positive socio-economic changes in the developing world. However, there are numerous instances of the employment of aggressive and grueling monitoring techniques which objectify the subject of development, the primary stakeholder, claiming development results as the successful achievement of goals of the donor or implementing organization. It is in this context that one can speak of an ethic of monitoring development programmes. The paper argues that such an ethic can be positively based on principles like empowering people through development work without hurting their sense of self-worth, the principle of trust and partnership and, negatively, never striving to objectify any person or people for the achievement of some objective, even if this objective is in itself honourable and desirable. The paper contends that if development is freeing the subject, the central player, to exercise their capability to live their life to the fullest, then development monitoring and development work in general has to enhance freedom, autonomy and openness.
In recent decades there has been increasing evidence of a relationship between self-reported racism and health. Although a plethora of instruments to measure racism have been developed, very few have been described conceptually or psychometrically. Furthermore, this research field has been limited by a dearth of instruments that examine reactions/responses to racism and by a restricted focus on African American populations. In response to these limitations, the 31-item Measure of Indigenous Racism Experiences (MIRE) was developed to assess self-reported racism for Indigenous Australians. This paper describes the development of the MIRE together with an opportunistic examination of its content, construct and convergent validity in a population health study involving 312 Indigenous Australians. The MIRE has considerable utility as an instrument that can assess multiple facets of racism together with responses/reactions to racism among indigenous populations and, potentially, among other ethnic/racial groups.
In light of increased access to policy dialogue about the reform of the international aid architecture, this paper explores ways in which southern researchers can maximise their input in to the debate. The authors argue that the current aid system is changing significantly, not only in terms of the increasing amounts of money which are likely to flow through the system, but also because of the range of new donors and funding vehicles which are joining it. This change is making the system more complex, and could potentially reduce the effectiveness of the aid that flows through it, but it also offers significant opportunities for reform. Specifically a number of decision-making fora have recently opened up which offer the chance for greater participation by southern organisations, particularly research institutes and think-tanks. To aid southern researchers’ affect on the debate the authors propose that they: target the content of the research; ensure it is in an appropriate medium and tailor it to the policy-makers; identify which international aid policy fora are most likely to take up their research; and increase focus on effective communication – researchers need to prepare a communications strategy to help to target their limited resources and capacity more effectively.
The new South African National Health Act has clarified that children may take part in ‘non-therapeutic' research (NTR) and the age at which they may provide independent consent to such research, viz. at legal majority. However, the Act will require consent from the Minister of Health for all research classed as NTR and involving minors regardless of the level of risk. This requirement is overly broad. It will require that low-risk research without direct benefits, which might be adequately reviewed by an accredited research ethics committee (REC), must also be reviewed by the Minister. As it currently stands this requirement is argued to serve no plausible ethical purpose, to cause delays and discourage essential research on the needs of children, and may inspire researchers and RECs alike to ‘foil the system'. The authors argue that in the long term there should be comprehensive law reform for child research. However, in the short term, amendments should be made to the Act to narrow the scope of this provision.
14. Useful Resources
Betteraid.org is a campaign website, published by the Civil Society International Steering Group (ISG) towards the Third High Level Forum on Aid Effectiveness in Accra in September 2008, reviewing the Paris Declaration. It aims to provide information and updates on aid effectiveness issues, especially related to the CSO parallel process towards the Third High Level Forum. The International Steering Group (ISG), initiated during the World Social Forum in Nairobi in January 2007, is actively voicing CSOs concerns and is preparing the CSO parallel Forum in Accra under the chairmanship of IBON Foundation and ISG active partners.
Qualitative synthesis has become more commonplace in recent years. Meta ethnography is one of several methods for synthesising qualitative research and is being used increasingly within health care research. However, many aspects of the steps in the process remain ill-defined. Meta-ethnography is a useful method for synthesising qualitative research and for developing models that interpret findings across multiple studies. Despite its growing use in health research, further research is needed to address the wide range of methodological and epistemological questions raised by the approach.
The Reporting Skills and Professional Writing Handbook (2nd Edition) is a self-study programme based on the best of 10 years' experience working with INGOs, NGOs,GOs and IOs over hundreds of training courses. It's available on CDROM for convenient desktop study, and, for larger organisations, the Trainer Edition is supported by a complete Training Pack. For people working in international development, it can be accessed for free on sign-up.
15. Jobs and Announcements
This course was developed to meet requests from individuals and organisations, for more effective planning, research and implementation of rational medicines use activities in the community. The objectives are: to study and remedy inappropriate medicines use in the community; to investigate and prioritize medicines use problems, and to develop effective strategies for change; and to address challenges in the use of medicines in the treatment of HIV/AIDS, tuberculosis and chronic diseases; including issues on treatment literacy and adherence. This two week course is aimed at policy makers, management staff from Ministries of Health, ARV programme managers, NGO officials responsible for national and local programmes, development aid agencies, social scientists, pharmacists and other public health workers. The deadline for receipt of applications is 2 May 2008. The course flyer and application form can be printed out directly from the Medicines web page at http://mednet3.who.int/prduc or www.uwc.ac.za/comhealth/soph
PHM is seeking a Community Organiser for six months May-October 2008. This is a temporary post based at the Alternative Information Development Centre (AIDC). The successful applicant will have excellent communication and organisational skills and be an effective team player; have experience of working in/with Civil Society Organisations; computer literacy; own transport; Excellent written and spoken English, Xhosa and/or Afrikaans; a history of involvement in social movement activity in health or a related area will be an advantage. She/he will be responsible for working with communities on the Right to Health campaign. Applicants should e-mail their CV and letter of application together with the names and contact details of two referees to Liz@phmsouthafrica.org. The closing date for applications will be 8 May 2008. Please note that only short listed applicants will be contacted.
This brief describes the workshops offered at the 4th Public Health Association of South Africa conference, to be held at the Holiday Inn, Strand Street in Cape Town from the 2nd-4th June. Registration details are available at http://phasa2008.mrc.ac.za
Published by the Regional Network for Equity in Health in east and southern Africa (EQUINET) with technical support from Training and Research Support Centre (TARSC).
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