This editorial is drawn from a speech by Dr Halfdan Mahler to the World Health Assembly in May 2008. Dr Mahler was the Director General of WHO at the time of the 1978 Alma Ata declaration on Primary Health Care. He stated at the 2008 WHA:
Milan Kundera wrote in one of his books: "The struggle against human oppression is the struggle between memory and forgetfulness." So allow me to remind all of us today, of the transcendental beauty and significance of the definition of health in WHO's Constitution: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
This definition is immediately followed by: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." Most importantly, the very first constitutional function of WHO reads: "To act as the directing and coordinating authority on international health work." Please do note that the Constitution says "the" and not "a" directing and coordinating authority.
So please, allow this old man in front of you to insist that unless we all become partisans in renewed local and global battles for social and economic equity in the spirit of distributive justice, we shall indeed betray the future of our children and grandchildren.
My memory tells me that the World Health Assembly had this in mind when, in 1977, it decided that the main social target for governments and WHO in the coming decades should be the attainment of what is known as "Health for All".
And, the Health Assembly described that as a level of health that will permit all the people of the world to lead socially and economically productive lives. The Health Assembly did not consider health as an end in itself, but rather as a means to an end.
That is, I believe as it should be.
When people are mere pawns in an economic and profit growth game, that game is mostly lost for the underprivileged.
Let me postulate that if we could imagine a tabula rasa in health without having to deal with the constraints - tyranny if you wish - of the existing medical consumer industry, we would hardly go about dealing with health as we do now in the beginning of the 21st century.
To make real progress we must, therefore, stop seeing the world through our medically tainted glasses. Discoveries on the multifactoral causation of disease, have for a long time, called attention to the association between health problems of great importance to man and social, economic and other environmental factors. Yet, considering the tremendous political, social, technical and economic implications of such a multidimensional awareness of health problems I still find most of today's so-called health professions very conventional, indeed.
It is, therefore, high time that we realize, in concept and in practice, that a knowledge of a strategy of initiating social change is as potent a tool in promoting health, as knowledge of medical technology.
Primary health care is indeed conditioned by its holistic framework and as such, may use different expressions. For example, in some countries health management has to be considered along with such things as producing more or better food, improving irrigation, marketing products, etc. It is not that people consider health services as unimportant, but there are things like getting food, or a piece of land, or house or an accessible source of water which are more of a life and death nature and must, in the wisdom of the people, come first to make other things meaningful. We have rarely considered these needs as falling within our expressed policies for health development and therefore, we risk being restricted, unilateral and ineffective in our action.
Again, I am afraid that conventional or medical wisdom has done very little to provide scientific and political credibility to the alleged importance of individual, family and community participation in health promotion.
These concerns, to which I have just alluded prompted an organizational study on "Methods of promoting the development of basic health services" by WHO's Executive Board in 1973 in which it is bluntly stated that:
"There appears to be widespread dissatisfaction of population about their health services for varying reasons. Such dissatisfaction occurs in the developed as well as in the Third World. The causes can be summarized as a failure to meet the expectations of the populations; an inability of the health services to deliver a level of national coverage adequate to meet the stated demands and the changing needs of different societies; a wide gap (which is not closing) in health status between countries, and between different groups within countries; rapidly rising costs without a visible and meaningful improvement in service; and a feeling of helplessness on the part of the consumer who feels (rightly or wrongly) that the health services and the personnel within them are progressing along an uncontrollable path of their own which may be satisfying to the health professionals but which is not what is most wanted by the consumer".
It was this organizational study by WHO's Executive Board that led to the decision by WHO in co-sponsorship with UNICEF to convene "The International Conference on Primary Health Care" in the city of Alma-Ata in 1978.
Let me then repeat with awe and admiration, the consensus concept of primary health care as contained in the Declaration of Alma-Ata 1978:
"Primary Health Care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part, both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community.
"It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process."
Let me also quote from the Declaration of Alma-Ata, that primary health care includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs. In my opinion, an admirable summation of key priorities.
Are you ready to address yourselves seriously to the existing gap between the health "haves" and the health "have-nots" and to adopt concrete measures to reduce it?
Are you ready to ensure the proper planning and implementation of primary health care in coordinated efforts with other relevant sectors, in order to promote health as an indispensable contribution to the improvement of the quality of life of every individual, family and community as part of overall socio-economic development?
Are you ready to make preferential allocations of health resources to the social periphery as an absolute priority?
Are you ready to mobilize and enlighten individuals, families and communities in order to ensure their full identification with primary health care, their participation in its planning and management and their contribution to its application?
Are you ready to introduce the reforms required to ensure the availability of relevant human resources and technology, sufficient to cover the whole country with primary health care within the next two decades at a cost you can afford?
Are you ready to introduce, if necessary, radical changes in the existing health delivery system so that it properly supports primary health care as the overriding health priority?
Are you ready to fight the political and technical battles required to overcome any social and economic obstacles and professional resistance to the universal introduction of primary health care?
Are you ready to make unequivocal commitments to adopt primary health care and to mobilize international solidarity to attain the objective of health for all by the year 2000?
Alma-Ata was, in my biased opinion, one of the rare occasions where a sublime consensus between the haves and the have-nots in local and global health emerged in the spirit of a famous definition of consensus: "I am not trying to convince my adversaries that they are wrong, quite to the contrary, I am trying to unite with them, but at a higher level of insight."
The Alma-Ata primary health care consensus also reflects a famous truism: "The Health Universe is only complete for those who see it in a complete light, it remains fragmented for those who see it in fragmented light!"
In conclusion, my personal view is that the Alma-Ata primary health care consensus has had major inspirational and operational impacts in many countries having a critical mass of political and professional leadership combined with adequate human and financial resources to test its adaptability and applicability within the local realities through a heavy dose of systems and operations research.
Mind you, it is much easier to be rational, audacious and innovative when your are rich! But, please, let us not forget that the inspirational energies and the evidence base came from the developing countries themselves, be they governmental or non-governmental sources.
For a majority of these countries, financial support from so-called donors was essential to carry out a broad array of studies, in appropriate technology, human resources development, infrastructure development, social participation, financing etc. in order to integrate the Alma-Ata vision into heavily constrained local contexts.
Most donors, after an initial outburst of enthusiasm quickly lost interest or distorted the very essence of the Alma-Ata Health for All Vision and Primary Health Care Strategy under the ominous name of selective primary health care which broadly reflected the biases of national and international donors and not the needs and demands of developing countries.
But in spite of these brutal impediments many developing countries have shown, before and after the Alma-Ata happening, courageous adhesion to its health message of equity in local and global health. Civil society movements have also been prime shakers and movers in these admirable efforts.
And so, being an inveterate optimist I do believe that the struggle between memory and forgetfulness can be won in favour of the Alma-Ata Health for All Vision and its related Primary Health Care Strategy. Let us not forget that visionaries have been the realists in human progression.
And so, distinguished audience, let us use the complete light generated by WHO's Constitution and the Alma-Ata Health for All Vision and Primary Health Care Strategy to guide us along the bumpy, local and global health development road.
Thank you.
1. Editorial
Uganda has implemented a number of reforms to its health sector to make services more accessible to poor communities, including abolishing user fees, introducing public-private partnerships in service delivery, and decentralizing the management of health services to district and lower local government levels. Yet poor people continue to face barriers to use of health services. Costs of health services are still cited by poor people as being a barrier to using services, as are long distances to health centers, particularly for rural residents. Access to health care is thus an important equity issue in Uganda: Poor and disadvantaged people experience a greater burden of disease - but have poorer access to health care than those who have higher incomes.
These were the challenges discussed at a recent national meeting on health equity in Uganda hosted by HEPS Uganda, Makerere University School of Public Health and EQUINET. The meeting included presentations of work on disparities in health and access to health care, from researchers from academic, government and non government organisations. While the presentations reported on a range of initiatives to improve health in the poorest communities, they also gave evidence of the continuing challenges the country faces.
For instance, one study reported by the Institute of Public Health at Makerere University found in three districts of Uganda that the poorest households were 2.4 times more likely to suffer ill health than the richest. Infant and child mortality among the poorest Ugandans are reported to be double that in the richest group. Such inequities are also common in vulnerable groups that have greater need for health care. Addressing the needs of the poorest communities can be overshadowed by deficits in access to care for a much wider group of people. For example, the meeting was informed that despite a significant improvement in access to antiretroviral therapy (ART), demand for ART has continued to outstrip supply, and only about 60% of people who need ART can access it. Older persons were also described as having high health needs that may not be met due to wider poverty and isolation.
Not surprisingly a number of papers in the meeting thus explored the way resources are allocated to address these challenges. The first issue that arose was the overall shortfalls in health financing. The US$14 per capita reported to be spent on health was noted to be about a third of the resources needed for minimum health care services. While new resources have been mobilised nationally and internationally for AIDS, presenters reported that there is still a significant shortfall in funding for AIDS, especially at the district level. It was reported that out-of-pocket payments continue to exceed public sector spending, even though most poor people use public services and through fees have been abolished in the public sector. This is a barrier to health care for poor communities, and the source of these charges needs to be better understood to address them. The continued shortfall in overall financing also draws attention to whether budgets give special consideration to vulnerable groups. Concern was expressed in one presentation that district councils set budget priorities using a narrow definition of gender health needs within the community. Women have weak control over productive resources and household finances, and unless services give additional attention to this situation they will also lack command over the resources they need to protect their health.
Such disparities remain an issue to be addressed to promote health and access to health care in Uganda. There was wide agreement that such inequalities were avoidable and thus merited attention and action. Some actions were presented and discussed: The experience of community health insurance schemes was reviewed as one option for supplementing health resources. A study was presented showing that 81% of households surveyed in one rural district expressed willingness to enroll in Community Heath Insurance schemes and were willing to contribute on average Ushs.5,977 (US$3.4) per person per year. Further work needs to be done on how equitable and sustainable these schemes are, especially for the poorest. It was argued that strengthening decentralisation, through resource allocation that prioritises districts and community level, could also go a long way to strengthening the health care system used by low income groups, and thus addressing inequity. Various examples were presented of strategies to empower and mobilise communities to engage with their health services, including the Village Health Team Strategy and the use of media, drama and of participatory reflection and action methodologies.
Across these options it was agreed that ensuring fair opportunities for health should not be left only to the Ministry of Health, but should be a matter for all sectors. According to the Ministry of Health in Uganda, over the past fourteen years, considerable effort has been made to restore the functional capacity of the health sector, through increasing public health spending, reactivating disease control programmes and re-orienting services to primary health care in Uganda. However, the ministry observed in a 2007 report that there still remain significant challenges in matching need for health services with available resources, making equity or fairness an important issue for advancing national policies for the population as a whole (http://www.health.go.ug/policies.htm).
The people and organisations at the national meeting agreed to continue networking to advance health equity work, and formed a new Ugandan health equity network. This will create a platform and ignite further action for health equity at national level. With leadership from different institutions working in these areas the network will share evidence, knowledge and strengthen advocacy on areas of health equity that include: resource mobilisation and allocation to the health sector; addressing health needs of vulnerable groups; protecting health in trade policies and agreements; and advancing health rights, community empowerment and effective governance in health. While it was evident in the meeting that a lot of work is underway, it is not always shared and communicated within Uganda and in the East and Southern Africa region. The delegates thus agreed to strengthen and widen links between people and institutions working on equity in health, to promote research and practice in this vital area of national health policy.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. For more information on the health equity network in Uganda, contact HEPS Uganda at heps@utlonline.co.ug, working with Makerere University School of Public Health. Further information on the issues raised and the report of the Uganda national meeting is also available at the EQUINET website at www.equinetafrica.org.
2. Latest Equinet Updates
This report of the second phase of this project outlines the work by a working group from the community in an informal settlement in Namibia and from the University to take forward community identified priorities for environmental health improvements, particularly sanitation. The report describes the engagement with the local authorities in a community driven process, and the challenges in building community empowerment for health actions in informal settlement areas. Community members have weak access to decision making on their services and actions to implement even the most basic PHC interventions take time to build the co-operation and responses from necessary stakeholders.
Over the past fourteen years considerable effort has been made to restore the functional capacity of the health sector, reactivate disease control programmes and re-orient services to Primary Health Care in Uganda. Ensuring that the resources for health fairly reach those with greatest need and that all have fair opportunities for health is a priority and not a matter for the Ministry of Health alone, but for all sectors whose activities affect health, and for all sections of society. As a part of this there is a body of work taking place in Uganda in government, academic and civil society institutions to explore, understand and propose options for reducing inequalities in health in Uganda. This abstract book presents the papers from a national meeting that aimed to assess the progress of equity in health in Uganda, review gaps and needs in the Ugandan health sector, to feed into and draw from experience in East and Southern Africa.
In this study, authors aimed to identify the impact of the migration of human resources for health on health services in Kenya. The World Health Organization (WHO) 2004 framework on health systems performance was used. The study concentrated on impacts on resource generation, stewardship and service provision and was limited to doctors and nurses. Despite data limitations, the study shows a general trend in migration both locally, from rural to urban areas and internationally, from Kenya to developed countries, with a high emigration rate of 51% for doctors and 71% of respondents indicating an intention to emigrate. From data collected, authors made a rough estimate of inward remittances of about US$90 million annually for nurses and doctors which, however, are not available to the health system and may not match outflows from the health system. In training doctors (schooling and university) alone, about US$95 million invested was lost in Kenya due to migration. Even if remittances were to be accounted for, there still appears to be a net outflow of capital from the country and its health system due to migration. This loss has negative impacts on workloads, especially at peripheral facilities and in some rural districts, which may impact on health service provision and on the referral chain. Increased workloads caused by understaffing result in stress, burn out and demotivation. These become push factors that lead remaining health workers to leave. There was some improvement in workloads in 2005/6 despite increases in service uptake, suggesting that there has been some policy response to the staff crisis in those facilities surveyed.
This study is a first attempt at gathering evidence on the effects of effects of user fee removal on aspects of utilisation and quality of services. The study was based on data collected from a sample of 23 districts in Zambia. The data included total utilisation, attendance levels at health centre outpatient and inpatient maternal and child health facilities, levels of respiratory infections, skin infections, diarrhoea and supervised deliveries, and the availability of drugs. Utilisation data is categorised by age (under-five years of age and over five years) and according to rural or urban districts. There was a substantial increase in total utilisation of public health services (50% increase in rural populations over 5) and an increase in drug consumption. Districts with a greater proportion of poor people recorded greater increases in utilisation of their facilities. Drug consumption in rural districts was estimated to have increased by about 40%. Staff workloads (calculated as the staff-to-patient ratio per day) in rural districts also showed a slight increase after user fees were removed. Based on patients' perceptions, there was no evidence of deterioration in the quality of care since user fees were removed. However, inadequate numbers of skilled health workers presents a major human resources threat to improving access by all. With sustained budget support from government to the DHMTs, the health system can continue to achieve its desired outcomes without relying on user fees.
To promote policies for equity in health HEPS-Uganda, Makerere University Institute of Public Health with EQUINET organised a National Meeting on equity in health in Uganda in March 2008. The meeting reviewed the body of work taking place in Uganda within government, academic and civil society institutions to explore, understand and propose options for reducing inequalities in health in Uganda. The meeting provided an opportunity to exchange evidence, strengthen networking in Uganda, and feed experience into regional networking. The report outlines the papers nd the deliberations. The meeting set up a task force that would take the work forward within key areas of focus, including fair financing; trade and health; health rights and governance and protection of vulnerable groups. HEPS and Makarere University Institute of Public Health are co-ordinating the task force. It was proposed that a follow up national meeting be held in a year to review issues and work.
The manual is intended for use by researchers in preparing papers, in writer’s training workshops; and will be updated in later editions with additional areas of writing skills. This edition of the manual is a guide to producing scientific reports, peer-reviewed articles, EQUINET policy and discussion papers, briefs and reports. It is intended for those involved in EQUINET and related research programmes to prepare papers for publication in reports, papers and in peer-reviewed, scientific journals; to communicate work on health equity; to understand and work with peer review processes; and to improve writing skills generally, including for meeting reports.
3. Equity in Health
The 61st World Health Assembly, which comprised of a record 2704 participants from 190 nations, set WHO on a course to tackle longstanding, new and looming threats to global public health. Among its achievements, the Health Assembly provided a platform for removing barriers and using innovative methods to encourage research, development and access to medicines for the common diseases of the developing world.
The conditions in which people live and work - the social determinants of health - help enhance or erode their health. At the direction of Health Assembly in 2005, the Commission on Social Determinants of Health has been examining these factors. The chair of the commission, Professor Sir Michael Marmot briefed delegates on the key recommendations of the commission's work. He said the commission's final report will pose recommendations under three action areas: the conditions of daily life; the structural drivers of those conditions; and the monitoring and training needed to measure progress. Concrete examples of implementing a social determinants approach to health were given from Brazil, Finland, India and Sri Lanka, as well as the International Organization of Migration. A common theme throughout the briefing was the need for more participation and representation from all stakeholder groups in these debates.
The delegates to the recently concluded National Meeting to assess the progress of equity in health in Uganda identified six areas for follow up work on equity for health in Uganda. These areas include: resource mobilisation and allocation to the health sector; health needs of the vulnerable groups; trade and health; governance and health rights. The meeting was organised by HEPS-Uganda and Makerere University School of Public Health, in co-operation with Regional Network for Equity in Health in East and Southern Africa (EQUINET), March 27-28, 2008. The meeting was convened to, among other things, review the gaps and needs in the health sector in Uganda; and to develop ways to strengthen networking and communication between people and institutions working in areas relevant to health equity.
4. Values, Policies and Rights
Most Ugandans are likely to go without essential medicines if the government does not take advantage of the flexibility provisions of the WTO’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) in the process of enacting the national intellectual property (IP) law. HEPS-Uganda’s review of the draft Industrial Property Bill 2007 established that while the draft bill attempts to incorporate the TRIPS flexibilities, some of them were drafted in a restrictive style such that Uganda may not derive maximum flexibility as envisaged by TRIPS Agreement, the Doha Declaration and other non-legally binding instruments.
Some thirty-five civil society organisations have voiced serious concerns over the World Health Organization's publications policy, arguing that the proposed policy, if implemented, will result in a tendency towards self-censorship by the WHO and its staff and HQ offices, to the detriment of the needs and interests of public health, especially in developing countries. They are also very concerned that this policy will hamper timely advice and support by WHO HQ and regional offices to member states over important issues such as application of intellectual property rights and the use of TRIPS flexibilities, other trade and health matters, reproductive health care and other critical issues.
The Convention on the Rights of Persons with Disabilities was adopted by General Assembly resolution A/RES/61/611 in 2006 and entered into force on 3 May 2008. The purpose of the Convention is to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity. Persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.
Proposed reforms to Angola's Penal Code have divided opinion in the country about whether HIV-positive people who intentionally infect others with the virus should be punished.The law under discussion calls for a sentence of between three and 10 years in prison for those who knowingly pass on infectious diseases, including HIV. Some argue that the law will act as a deterrent; others say it will bring more problems than benefits.
5. Health equity in economic and trade policies
At a hearing on 16 May 2008 in the US Court of Appeals for the Ninth Circuit, public health and health professionals will demand that corporate interests be balanced with public interest representation on US Industry Trade Advisory Committees (ITACs) that advise the US Trade Representative (USTR) on trade policies affecting public health. Non-profit and public interest organizations have been systematically denied posts on industry-dominated trade advisory committees that impact the health of millions of people around the world.
The global strategy on public health, innovation and intellectual property aims to promote new thinking on innovation and access to medicines, as well as, provide a medium-term framework for securing an enhanced and sustainable basis for needs driven essential health research and development relevant to diseases which disproportionately affect developing countries, proposing clear objectives and priorities for Research and Development, and estimating funding needs in this area. In resolution WHA59.24 the Health Assembly recognised the growing burden of diseases and conditions that disproportionately affect developing countries, and particularly women and children. Reducing the very high incidence of communicable diseases in those countries is an overriding priority. At the same time, it is important for WHO Member States and the WHO Secretariat to recognise and better address the increasing prevalence of non-communicable diseases in those countries. This document serves as the outcome-document of the agreements made on 3 May 2008.
This publication, on negotiations about trade in services indicates ways that human rights advocates can get involved to ensure their governments do not sign agreements that could have harmful human rights effects. Access to essential services, including water, education and health care are on the table as representatives at the WTO push for closure to trade talks in the coming months. Advocates must act now to ensure these agreements include full consideration of the potential human rights impacts of new policies. This Action Alert sets out actions and strategies for human rights advocates concerned about the issue.
Parliamentarians are pressurising Uganda to revoke the interim trade agreement signed between the European Union and the East African Community. The Ugandan MPs claim the partial Economic Partnership Agreement (EPA) signed at the close of last year entrenches 'unfair treatment' of the five-member bloc. The Parliamentary Committee on Trade, Industry and Tourism is presently evaluating the significance of the trade relationship with EU, following a petition from over a dozen civil society groups.
This is a short report on the negotiations at the Intergovernmental Working Group on Public Health, Innovation and Intellectual Property. Once again, negotiations were considered unsuccessful by the developing countries as developed countries sought to maintain the status quo, which gives them unfair advantages in intellectual property rights. Negotiations were replete with instances of chicanery and doublespeak on the part of most developed countries, led by the United States. The principal thrust of their strategy has been to obstruct any forward looking measure that would promote the basic objectives of the IGWG, objectives that were designed to find real mechanisms that can promote both innovation and access to medicines that are required for the poor in developing countries.
WHO Director General Margaret Chan at the 61st World Health Assembly, raised intellectual property issues optimistically, as an opportunity for the organisation to make a difference. Chan highlighted a report due out later this year from the Commission on Social Determinants of Health, which she 'should help us address the root causes of inequities with greater precision'. She then commended members for the 'tremendous progress' made in meetings of the Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property (IGWG).
6. Poverty and health
The regressive food policies imposed on poor countries by the World Bank and IMF are codified and enforced by the World Trade Organization's Agreement on Agriculture (AoA). The AoA, as Afsar Jafri of Focus on the Global South writes, is "biased in favour of capital-intensive, corporate agribusiness-driven and export-oriented agriculture." AoA should be abolished, and Third World countries should have the right to unilaterally cancel liberalization policies imposed through the World Bank, IMF, and WTO, as well as through bilateral free trade agreements such as NAFTA and CAFTA.
In the last decade a number of initiatives have been used in Malawi to tackle the issue of household food insecurity. One of the most controversial has been the Starter Pack programme launched in 1998. Initially consisting of a free handout of packs of improved maize seed, legumes and fertiliser to every small holder farm household in Malawi the scheme, under donor pressure, was subsequently scaled down to become a form of targeted social safety net programme. This paper analyses the strengths and weakness of both the original programme and its scaled down version.
The objectives of the study were: to compare the nutritional status of participants (children who participate in the school lunch) and non-participants (children who do not participate in the school lunch) and to assess the diet quality of the school and home lunch. It was hypothesized that the nutritional status of participants was better than that of the nonparticipants. Three hundred and twenty pupils (index children) and their parents were randomly selected for the purpose of the study. Anthropometric measurements, 24-hour recall, interview schedules and observed weighed technique were the instruments used in data collection. The results indicated a positive association between the school lunch and nutritional status. The diet quality of the school lunch and nutritional status of participants were significantly higher than that of the non-participants. More schools and parents in similar environments should therefore be encouraged to venture into the SLP because of their positive outcome on nutritional status as well as the diet quality of participating children.
This article provides evidence on the link between poverty and risky sexual behaviour. It examines the effect of wealth status on age at first sex, condom use, and multiple partners using data from more than 19,000 adolescents from Burkina Faso, Ghana, Malawi and Uganda. The results show that the wealthiest girls in Burkina Faso, Ghana and Malawi have later sexual debut compared with poorer adolescents, but this association was not significant in Uganda. Wealth status is weaker among males and significant only in Malawi, where those in the middle income group had earlier sexual debut. Wealthier adolescents were most likely to use condoms, but wealth status was not associated with the number of sexual partners. The authors conclude that understanding patterns and motivations of early sexual debut, non-use of condoms, and multiple partnerships is an important contribution to HIV prevention strategies. From this study poverty appears to influence early sexual debut, especially among females, and the poor are less likely to be using condoms. Therefore, poverty, by influencing sexual behaviour and access to services, can influence the transmission of HIV infection.
Poverty is the underlying cause of child deaths in South Africa, according to a recent study released by the Medical Research Council. But other sub-Saharan African countries, with less money and fewer resources, have managed to cut their child mortality rates. A recent study in The Lancet reported that deaths in children under age five have been dropping in Tanzania, whereas between 2000 and 2004 child mortality dropped by 24 percent. During this period, the Tanzanian government increased the annual amount spent on healthcare per citizen from 4.70 to 11.70 (about R36 to R89,60). The money was also evenly distributed across the country, rather than favouring richer districts.
This paper explores the prospects of poverty reduction with particular reference to health services to older people in Tanzania. Tanzania’s National Ageing Policy raises a number of questions on the health of older people some of which are answered by the country’s National Strategy for Growth and Reduction of Poverty. This paper aims to analyse and establish the prospects of improvement of health services to older people in Tanzania, including: do the poverty reduction initiatives sufficiently address the obstacles of access to health services by older people; and does the fact that the poverty reduction initiatives are being pursued hand in hand with measures to overcome past failures of the state in planning such as decentralization and participatory strategic planning in the local areas make a difference? The researchers found that while the long term objective of government to make free health services available to older people is not in doubt, it is not yet clear how the objective will be achieved. It is still some way into the future that such bold policies will be translated into action backed by allocation of financial and human resources. Furthermore, the general national strategy for growth and reduction of poverty needs to be operationalised with sector and area specific programmes and plans, in this regard by Health ministry programmes and health plans of Local Governments.
The Essential Nutrition Actions package is an approach to expand the coverage of seven affordable and evidence-based actions to improve the nutritional status of women and children, especially those under two years of age. The Food and Nutrition Technical Assisstance Project (FANTA)'s Review of Incorporation of Essential Nutrition Actions into Public Health Programs in Ethiopia found that the approach has been incorporated into the Ethiopia Federal Ministry of Health system and multilateral and NGO programming, however, improved training and other steps are necessary to further institutionalise the approach. The review, requested by USAID/Ethiopia, examined a number of facilitating and inhibiting factors to ENA integration in the context of Ethiopia’s health system.
7. Equitable health services
Former Director General of WHO (1973-1988), Halfdan Mahler, said Primary Health Care is essential health care based on scientifically and socially sound methods and technologies that is made available to everyone. It was inspirational to an earlier generation but lost its primary place in public health when it was replaced by vertical programmes, like smallpox eradication, with their single goal, funding and response structure. He cautioned a room packed with hundreds of delegates that to make real progress we should stop seeing the world through medically-tinted glasses. Citing the 'transcended beauty of the Constitution of the WHO', he said that PHC aims to address inequity and social injustices that still plague countries.
More than 40 delegations at the WHA described the status of immunization in their countries, their efforts, future plans and successes. The 68% reduction in measles deaths globally in just six years of accelerated activities points to the potential for such achievements in other areas of immunisation. Constraints raised by governments included financial support especially for new, more expensive life-saving vaccines and for low middle-income countries who are not eligible for support from the GAVI Alliance. The importance of high data quality and injection safety were also of concern to Member States.
Under-treatment, inappropriate treatment and lack of education for asthma patients in South Africa are contributing to still unacceptably high morbidity rates. The most recent figures reveal that at least 10 percent of South Africans have asthma with many still dying unnecessarily, especially people in poorer households. Asthma deaths are almost all preventable and a 2004 report by the Global Initiative for Asthma found that South Africa has the world's fourth highest asthma death rate among five- to 35-year-olds. Out of every 100 000 South Africans with asthma, 18,5 die of the illness. Asthma therapy is freely available in the government health service. The most effective means of controlling asthma is to use a preventer pump containing an anti-inflammatory. The most cost-effective way of relieving an attack is a pump with a bronchodilator. A study by the University of Pretoria to understand the impact (including the impact on health-related quality of life) of asthma on South African asthmatics found that patients were not accessing treatment or were being inappropriately treated.
WHO Assistant Director General for health systems, Carissa Etienne, stressed the need for evidence, information and research to make cost-effective health policies in developing countries. Specifically, she called for a systematic review of all research on primary health care since Alma Ata to provide real evidence on what works and fails, as well as for research on Community health workers – all against a measure of health outcomes.
A cross-sectional study was conducted, based on systematic sampling of consecutive patients with pulmonary tuberculosis (TB) symptoms and who attended the TB clinic for their medication at Ilala District Hospital, Tanzania. Over half the patients (54.3%) admitted that they openly speak about their illness to others but that only one-third (33.3%) of their friends and family responded in a considerate and sympathetic manner. One-third (36.6%) of the friends and relatives became less friendly and the remaining one-third openly portrayed fear and tried to discriminate the patient even after the commencement of medications. The patients' compliance rate was 100%. The counselling received from the health personnel along with the patients' own motivations to improve their health, was the main driving force in seeking treatment and taking daily medication. Discrimination against TB patients by relatives and friends is likely to hinder positive health seeking behaviour and thus impede control of this disease. This paper discusses identified areas where effort is needed to improve the early management of TB patient.
This research sought to establish the efficacy of the current referral system of critical care patients: (i) from public hospitals with no ICU or HCU facilities to hospitals with appropriate facilities; and (ii) from public and private sector hospitals with ICU or HCU facilities to hospitals with appropriate facilities. A 100% sample was obtained; 77% of public and 16% of private hospitals have no IC/HC units. Spread of hospitals was disproportionate across provinces. There was considerable variation (less than 1 hour - 6 hours) in time to collect between provinces and between public hospitals that have or do not have ICU/HCU facilities. In the private hospitals, the mean time to collect was less than an hour. In public hospitals without an ICU, the distance to an ICU was 100 km or less for about 50% of hospitals, and less than 10% of these hospitals were more than 300 km away. For hospitals with units (public and private), the distance to an appropriate hospital was 100 km or less for about 60% of units while for 10% of hospitals the distance was greater than 300 km. For public hospitals without units most patients were transferred by non-ICU transport. In some instances both public and private hospitals transferred ICU patients from one ICU to another ICU in non-ICU transport. A combination of current resource constraints, the vast distances in some regions of the country and the historical disparities of health resource distribution represent a unique challenge which demands a novel approach to equitable health care appropriation.
The Klerksdorp/ Tshepong Hospital Complex have introduced an Escorting Project, which will allow nursing assistants to accompany referral patients to Johannesburg hospitals. The project aims to ensure that patients receive quality care and reduce waiting times. The hospital is the largest provincial hospital operating as the referral hospital for Dr K Kaunda District, Ruth Mopati District as well as tertiary services for the entire province. Hospital Chief Executive Officer, Kathy Randeree said that the hospital recently undertook a mini-survey to determine how best to assist patients who are accessing health services in Gauteng Hospitals. She said that the survey recommended the launch of the project with management resolving to have a pool of escorts for Klerksdorp/ Tshepong hospital so that referred patients are able to have the assistance of an allocated escort for the various hospitals and clinics in Gauteng.
Some 35% of antimalarial drugs sold in six major African cities failed basic quality tests. The cities were in Ghana, Kenya, Nigeria Rwanda, Tanzania and Uganda. Artemisinin monotherapies, which the World Health Organisation explicitly rejects as substandard, remain common in Africa. Substandard antimalarial drugs cause an estimated 200,000 avoidable deaths each year.
The study aimed to examine the medical referral pattern of patients received at the Muhimbili National Hospital (MNH) in Tanzania to inform the process of strengthening the referral system. This prospective study was conducted at MNH during a 10-week study period from January to March 2004. The study sample consisted of patients referred to MNH. Of the 11,412 patients seen, 72.5% were self-referrals. More than 70% of the patients seen required admission, though not necessarily at tertiary level. Only 0.8% came from outside the Dar es Salaam region. More than 70% of the patients seen required admission. Surgical services were required by 66.8% of patients, with obstetric conditions being most prominent (24.6% of all patients). For those who were formally referred from other health services, lack of expertise and equipment were the most common reasons given for referral (96.3%). Efforts to improve referral systems in low-income countries require that the primary and secondary level hospitals services be strengthened and increased to limit inappropriate use of national referral hospitals.
The US$ multi-billion a year GAVI Alliance is spending a fraction of its budget to help its vaccines get to the end of the track, by strengthening health systems in a group of countries in central America, Africa and Asia. GAVI provides support directly to country governments, not through other agencies. Also its large budget and global nature encourages vaccine manufacturers to take a positive view of developing country markets – and thus add relevant, affordable products to their portfolios.
8. Human Resources
The number of people currently being trained to become health workers falls far below the levels needed to ensure health goals are met, according to the Global Health Workforce Alliance (GHWA), a WHO partnership. The 2006 World Health Assembly Resolution (59.23) called on all Member States to help rapidly increase the number of health workers. In response, GHWA asked a group of experts to review and report on the experiences and research from around the world, and to draw up proposals on how to scale up the education and training of health workers. Drawing on case studies from 10 countries, the report details a set of recommendations.
There is significant concern about the worldwide migration of nursing professionals from low-income countries to rich ones, as nurses are lured to fill the large number of vacancies in upper-income countries. This study explores the views of nursing students in Uganda to assess their views on practice options and their intentions to migrate. Most (70%) of the participants would like to work outside Uganda, and said it was likely that within five years they would be working in the US(59%) or the UK(49%). About a fourth (27%) said they could be working in another African country. Only eight percent of all students reported an unlikelihood to migrate within five years of training completion. Survey respondents were more dissatisfied with financial remuneration than with any other factor pushing them towards emigration. Those wanting to work in the settings of urban, private, or UK/US practices were less likely to express a sense of professional obligation and/or loyalty to the country. Those who have lived in rural areas were less likely to report wanting to emigrate. Students with a desire to work in urban areas or private practice were more likely to report an intention to emigrate for financial reasons or in pursuit of country stability, while students wanting to work in rural areas or public practice were less likely to want to emigrate overall.
The world's leading health and hospital professional associations have joined to produce the first-ever joint guidelines on incentives for the retention and recruitment of health professionals. Underlining both financial and non-financial incentives as critical to ensuring effective recruitment, retention and performance of health workers across the world, the Guidelines on Incentives describe different approaches taken by a number of countries. Examples of financial incentives cited include tax waivers, allowances (e.g. - housing, clothing, child care, remote location weighting etc.), insurance, and performance payments. Examples of non financial incentives include ensuring positive work environments, flexibility in employment arrangements and support for career development. The report underlines how incentives are important levers that organisations can use to attract, retain, motivate and improve the performance of their staff in all professions and walks of life. This is especially and urgently needed in the health care sector, where the growing gap between the supply of health care professionals and the demand for their services is reaching crisis levels in many countries.
This paper reports on a study into the delivery of services and care at the Muhimbili National Hospital, to measure the extent to which workers in the hospital were satisfied with the tasks they performed and to identify factors associated with low motivation in the workplace. Almost half of both doctors and nurses were not satisfied with their jobs, as was the case for 67% of auxiliary clinical staff and 39% of supporting staff. Among the contributing factors reported were low salary levels, the frequent unavailability of necessary equipment and consumables to ensure proper patient care, inadequate performance evaluation and feedback, poor communication channels in different organisational units and between workers and management, lack of participation in decision-making processes, and a general lack of concern for workers welfare by the hospital management. Based on the study findings, several recommendations were made, including setting defined job criteria and description of tasks for all staff, improving availability and quality of working gear for the hospital, the introduction of a reward system commensurate with performance, improved communication at all levels, and introduction of measures to demonstrate concern for the workers' welfare.
The European Economic and Social Committee decided to draw up an opinion, under Rule 29(2) of its Rules of Procedure, on Migration and development: opportunities and challenges. It says the process of globalisation has led to the liberalised movement of capital, goods, and services. The movement of people, however, still remains globalisation's most restricted branch. In order to give less-developed economies a bigger share of the economic growth driven by globalisation, more attention should be given to the free movement of people. This opinion follows the school of thought that migration is a chance for developing countries to participate more equally in today's globalised economy and that migration has the potential to decrease inequality.
The imbalances in Human Resources for Health that result from health professionals crossing borders of districts, countries, and moving from private to public sectors and vice versa or leaving health services to join other non-health related business leads to inequity in delivery of health services, especially in the parts of the world that do not have sufficient incentives to attract these professionals. This study compared attrition rates in three Private-Not-For-Profit and three Government General Hospitals in West Nile Region over a period of five years. It also examined the destination to which the health professionals were lost, the source of the new staff that replaced those lost by the hospitals, the reasons for attrition as perceived by the existing staff in the hospitals, what kept some of the staff working for longer period than others who chose to leave, and the incentives in place for attraction and retention of health professionals in these hospitals.
Multiple health programmes are using unpaid or low-paid community volunteers, and other sectors such as environment, water and agriculture are doing the same. A new study of reimbursement of health volunteers is revealing the need for an internationally agreed strategy. Community volunteers – unpaid or very poorly paid local workers from the villages and slums of developing countries – are proving increasingly valuable to many health, water and agricultural programmes. But as this gets more widely known, programmes using them are beginning to overlap, some in the same villages and some even with the same volunteers – while there is no coherent policy for how “use” or to reward them. This is reported in the paper to be an unsustainable form of exploitation as demands and expectations of these people increase.
9. Public-Private Mix
The Health Sector Strategic Plan (HSSP) aims to ensure access to basic health care by the Ugandan population through the delivery of the National Minimum Health Care Package (NMHCP). This requires availability of well-trained health professionals. This study demonstrates that the Private-Not-For-Profit (PNFP) Health Training Institutions - the majority in Uganda - have remained grossly under-funded, which poses a threat to achievement of the HSSP. They are faced with decreasing income from fees, dwindling donor support and over-dependence on government grants which are both uncertain and erratic. Consequently, vital activities for students' training such as field trips, teaching and reading materials are left unsatisfied as a copying mechanism, but not without negative implications for quality. It is recommended that government increases and guarantees its support to these Health Training Institutions as a way of maintaining quality of health worker training. At the same time, the training institutions need to diversify their funding options to include designing short tailor-made courses, mobilising alumni contributions, research and consultancies, self-help projects like farming, canteens and stationeries as well as fund-raising activities as a way of bridging their funding gap. This should be coupled with more efficiency mechanisms and prudent management to avoid wastage of the already scarce financial resources.
This paper traces the history of the public-private partnership for health (PPPH) in Uganda, giving its justification and mandate. It also gives its current state of the art, outlining the successes scored, the challenges still faced in its implementation and current efforts being made to make it comprehensively institutionalised. The successes include the bilateral acceptance of the principle and need for partnership by both the public and private partners, the overt gestures by the public partner through direct funding of the private providers, the ceding of some responsibilities to private players, the acceptance by the private players to take on some public responsibilities using their own resources etc. The challenges include the slow formalisation of the partnership, scepticism about autonomy, the stagnation of government funding, the poor understanding of the partnership at sub-national levels and poor sharing of information, among others. These challenges are now further compounded by the recent introduction of new policy reforms like fiscal decentralisation to the same local officials who do not fully appreciate the partnership and are therefore not likely to support it. The paper concludes with some useful suggestions on how these challenges may be tackled.
10. Resource allocation and health financing
African heads of state and government must not revise or further delay implementation of AU Abuja April 2001 15% health commitment says Archbishop Desmond Tutu & 15% Now Campaign. One hundred and forty-one African and global organisations and networks call on African leaders and finance ministers to restate 15% commitment at next AU Summit in Egypt.
The loss of over 8 million lives a year to preventable, treatable, and manageable diseases and health conditions is not acceptable or unsustainable. The African Union's Public Health 15% Now Campaign has launched a 30 day countdown to the mid year African Union summit to be held in Egypt from the 24th of June. The 30 day countdown which starts from the 15th of May to the 15th of June is aimed at mobilising national level and continental support for a civil society message to urge African Heads of States to restate their commitment to and urgently implement the Abuja 2001 pledge by African Heads of State to allocate 15% of national budgets to health.
Some donors and governments propose that health insurance mechanisms can close health financing gaps and benefit poor people. Although beneficial for the people able to join, this method of financing health care has so far been unable to sufficiently fill financing gaps in health systems and improve access to quality health care for the poor. Donors and governments need to consider the evidence and scale up public resources for the health sector. Without adequate public funding and government stewardship, health insurance mechanisms pose a threat rather than an opportunity to the objectives of equity and universal access to health care. This study presents the evidence for and against different models of social health insurance for developing countries. It concluded that models should be assessed for whether they increase universal access including to poorest and most vulnerable.
It has been argued that quality improvements that result from user charges reduce their negative impact on utilisation especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1 March 2001. Different quality variables assessed showed that interventions that were put in place were able to maintain, or improve the technical quality of services. There were significant increases in utilisation of services, average drug quantities and stock out days improved, and communities reported health workers to be hardworking, good and dedicated to their work. The levels of technical quality of care attained in a system with user fees can be maintained, or even improved without the fees through adoption of basic, sustainable system modifications that are within the reach of developing countries. However, a trade-off between residual perceptions of reduced service quality, and the welfare gains from removal of user fees should guide such a policy change.
This retrospective analysis of routine programme data from Mbagathi District Hospital, Nairobi, Kenya shows the difference in rates of loss to follow-up between a cohort that paid 500 shillings/month (approximately US$7) for antiretroviral drugs (ART) and one that received medication free of charge. A total of 435 individuals (mean age 31.5 years, 65% female) was followed-up for 146 person-years: 265 were in the 'payment' cohort and 170 in the 'free' cohort. The incidence rate for loss to follow-up per 100 person-years was 47.2 and 20.5, respectively (adjusted hazard ratio 2.27, 95% CI 1.21-4.24, P=0.01). Overall risk reduction attributed to offering ART free of charge was 56.6% (95% CI 20.0-76.5). Five patients diluted their ART regimen to one tablet (instead of two tablets) twice daily in order to reduce the monthly cost of medication by half. All these patients were from the payment cohort. Payment for ART is associated with a significantly higher rate of loss to follow-up, as some patients might be unable to sustain payment over time. In resource-limited settings, ART should be offered free of charge in order to promote treatment compliance and prevent the emergence of drug resistance.
The potentially destructive polarisation between 'vertical' financing (aiming for disease-specific results) and 'horizontal' financing (aiming for improved health systems) of health services in developing countries has found its way to the pages of Foreign Affairs and the Financial Times. The opportunity offered by 'diagonal' financing (aiming for disease-specific results through improved health systems) seems to be obscured in this polarisation.In April 2007, the board of the Global Fund to fight AIDS, Tuberculosis and Malaria agreed to consider comprehensive country health programmes for financing. The new International Health Partnership Plus, launched in September 2007, will help low-income countries to develop such programmes. The combination could lead the Global Fund to fight AIDS, Tuberculosis and Malaria to a much broader financing scope. This evolution might be critical for the future of AIDS treatment in low-income countries, yet it is proposed at a time when the Global Fund to fight AIDS, Tuberculosis and Malaria is starved for resources. It might be unable to meet the needs of much broader and more expensive proposals. Furthermore, it might lose some of its exceptional features in the process: its aim for international sustainability, rather than in-country sustainability, and its capacity to circumvent spending restrictions imposed by the International Monetary Fund. The authors believe that a transformation of the Global Fund to fight AIDS, Tuberculosis and Malaria into a Global Health Fund is feasible, but only if accompanied by a substantial increase of donor commitments to the Global Fund. The transformation of the Global Fund into a 'diagonal' and ultimately perhaps 'horizontal' financing approach should happen gradually and carefully, and be accompanied by measures to safeguard its exceptional features.
This is a short commentary on Namibia's 2008 Budget by a Namibian health professional with regard to the Millenium Development Goals. A deep look at the budget reveals some problematic areas, namely that the Minister of Health once more missed the opportunity to allocate adequate resources to health. She again missed the Abuja target by 5%, which by international consensus, considers a 15% government budget allocation to health as satisfactory. Although it was said that the health budget has been increased by 26%, the total health and social services allocation is still standing at 10.08% of the overall Government budget for the 2008-09 financial year. This is a missed opportunity, given that the Minister had enough cash for a fair distribution to national priorities, health included.
This paper discusses the degree to which social cash transfer schemes that do not explicitly target HIV and AIDS affected persons or households reach HIV and AIDS affected households. By comparing different schemes in Zambia, Malawi and South Africa, the study identifies the main factors that determine both the share of HIV and AIDS affected households reached, and the impact achieved. The authors find that in terms of the share of HIV and AIDS affected households benefiting from the scheme, the Zambia and Malawi schemes seem to have the highest share of HIV and AIDS affected households as a percentage of all beneficiary households. About 70 per cent of the beneficiary households seem to be HIV and AIDS affected, even though they do not use HIV and AIDS as a targeting criterion. With regard to focusing on the ultra poor and neediest of the HIV and AIDS affected households the Zambia and Malawi schemes score high whereas the South African schemes score low. In the impact on children in HIV and AIDS affected households reached by the different schemes, the South African ones score highest. The generous amounts transferred by these schemes go some way to ensuring that the basic needs of children are met.
11. Equity and HIV/AIDS
Developing countries have several international trade law provisions at their disposal to help them buy life-saving medicines at affordable prices for public health needs, particularly HIV/AIDS. But only a few countries are using these because of red tape and political pressure. This article looks at what WHO is doing to support countries in using international trade law effectively to secure medicines.
In a rare study of mortality before and after ARVs, researchers have found a drop in deaths of 10 percent. Free antiretroviral therapy has significantly reduced mortality in rural Malawi. The researchers investigated the mortality in a population before and after the introduction of free ARVs, in turn measuring the effects of such programmes on survival rates in the population. Researchers measured the mortality in a population of 32,000 in northern Malawi, from August 2002 when free ARV therapy was not available in the district, until February 2006, eight months after an ARV clinic was opened. Comparisons revealed that overall mortality rates among adults had declined by 10 percent. This equalled nine deaths averted in an eight-month observation period after the introduction of ARVs. Mortality decreased by 35 percent in adults near the district’s main road, where death rates before antiretroviral therapy were highest.
Malawi, which has about 80000 deaths from AIDS every year, made free antiretroviral therapy available to more than 80000 patients between 2004 and 2006. The authors aimed to investigate mortality in a population before and after the introduction of free antiretroviral therapy, and therefore to assess the effects of such programmes on survival at the population level. The study used a demographic surveillance system to measure mortality in a population of 32000 in northern Malawi, from August, 2002, when free antiretroviral therapy was not available in the study district, until February, 2006, 8 months after a clinic opened. The probability of dying between the ages of 15 and 60 years was 43% (39-49) for men and 43% (38-47) for women; 229 of 352 deaths (65.1%) were attributed to AIDS. Eight months after the clinic that provided antiretroviral therapy opened, 107 adults from the study population had accessed treatment, out of an estimated 334 in need of treatment. Overall mortality in adults had decreased by 10% from 10.2 to 8.7 deaths for 1000 person-years of observation (adjusted rate ratio 0.90, 95% CI 0.70-1.14). Mortality was reduced by 35% (adjusted rate ratio 0.65, 0.46-0.92) in adults near the main road, where mortality before antiretroviral therapy was highest (from 13.2 to 8.5 deaths per 1000 person-years of observation before and after antiretroviral therapy). Mortality in adults aged 60 years or older did not change. Findings of a reduction in mortality in adults aged between 15 and 59 years, with no change in those older than 60 years, suggest that deaths from AIDS were averted by the rapid scale-up of free antiretroviral therapy in rural Malawi, which led to a decline in adult mortality that was detectable at the population level.
Something is definitely not quite right with the concept or delivery of Prevention of Mother-to-Child HIV Transmission (PMTCT) services. While uptake has been known to be poor, in spite of policy guidelines that require all expectant mothers seeking antenatal care to be counselled and offered an HIV test, it has now emerged that health workers are having to contend with a significant number of rural women who reject positive results. HEPS-Uganda has found worrying cases of expectant mothers who consent to an HIV test in Kamwenge in western Uganda turn around to decline positive tests. In a December 2007 project report, 'Community Empowerment and Participation in Maternal Health in Kamwenge District', HEPS-Uganda says that while its project resulted in more pregnant women seeking ANC services, a big proportion of them still refuse to consent to voluntary HIV counselling and testing (VCT) services and that some of the few who consent do not accept their results.
This study was conducted to identify reasons for a high and progressive loss to follow-up among HIV-positive mothers within a prevention-of-mother-to-child HIV transmission (PMTCT) program in a rural district hospital in Malawi. Three focus group discussions were conducted among a total of 25 antenatal and post-natal mothers as well as nurse midwives (median age 39 years, range 22–55 years). The main reasons for loss to follow-up included: not being prepared for HIV testing and its implications before the antenatal clinic (ANC) visit; fear of stigma, discrimination, household conflict and even divorce on disclosure of HIV status; lack of support from husbands who do not want to undergo HIV testing; the feeling that one is obliged to rely on artificial feeding, which is associated with social and cultural taboos; long waiting times at the ANC; and inability to afford transport costs related to the long distances to the hospital. This study reveals a number of community- and provider-related operational and cultural barriers hindering the overall acceptability of PMTCT that need to be addressed urgently. Mothers attending antenatal services need to be better informed and supported, at both community and health-provider level.
This study assessed the role of governmental and non-governmental organisations in mitigation of stigma and discrimination among people infected and affected by HIV/AIDS in informal settlements of Kibera. More than 61% of the respondents had patients in their households. Fifty-five percent (55%) of the households received assistance from governmental and non-governmental organisations in taking care of the sick. Services provided included awareness, outreach, counselling, testing, treatment, advocacy, home based care, assistance to the orphans and legal issues. About 90% of the respondents perceived health education, counselling services and formation of post counselling support groups to combat stigma and discrimination to be helpful. Stigma and discrimination affects the rights of People Living with HIV/AIDS (PLWHAs). Such stigmatisation and discrimination goes beyond and affects those who care for the PLWHAs, and remains the biggest impediment in the fight against HIV/AIDS in Kibera. Governmental and non-governmental organizations continue to provide key services in the mitigation of stigma and discrimination in Kibera. However, personal testimonies by PLWHAs showed that HIV positive persons still suffer from stigma and discrimination. About 43% of the study population experienced stigma and discrimination.
HIV/AIDS treatment guidelines for South Africa's public health sector are out of sync not only with those of many other countries in the region, but also with the latest research on how to most effectively treat people living with HIV. Various studies indicating that patients who start antiretroviral therapy (ART) earlier respond better to treatment and are less likely to develop AIDS-related illnesses have led the United States, the United Kingdom and a number of countries in Africa to change their treatment protocols. Deciding when to start a patient on life-long ARV drugs is usually based on a combination of CD4 cell count test results [which indicate the strength of the immune system] and HIV disease progression, which the World Health Organisation (WHO) has defined according to four clinical stages, with stage four being AIDS. The WHO revised its guidelines in 2003 to recommend that a patient who has reached stage three of the disease and has a CD4 count of less than 350 should begin treatment. Most countries in the region have revised their guidelines accordingly, but South Africa's national ART guidelines are still based on earlier WHO recommendations that ART be prescribed only for patients with stage four disease, or a CD4 count of less than 200. In April, the Southern African HIV Clinicians Society published guidelines in the Southern African Journal of HIV Medicine recommending that people living with HIV begin ART when their CD4 cell count drops below 350, regardless of disease progression. These guidelines are endorsed by the region's leading HIV specialists but have no direct influence on the South African government's ART programme.
Since the beginning of the HIV epidemic, governments have prevented people living with HIV from entering or residing in their countries based solely on their HIV status. Such restrictions have stopped HIV positive people from travelling for business, family visits, or tourism; and from entering a country for study, labour migration, and political asylum. Seldom is HIV testing linked to any treatment, heath care, counselling or support, either in country of origin or destination. Nor are the results necessarily kept confidential. Though countries focus on excluding HIV positive migrants, little is done to protect migrants from HIV infection while in destination countries – and indeed some do get infected. There have also been reports of HIV-positive migrants dying for lack of treatment while abroad, including in immigration detention facilities pending deportation. HIV-travel restrictions are anachronisms that are inappropriate in the age of globalisation, increased travel, increased access to treatment for HIV, and national and international commitments to universal access to HIV prevention, treatment, care and support. They are also discriminatory and contribute to stigmatisation. No evidence suggests that HIV-related travel restrictions protect the public health, and they may in fact impede efforts to stop the epidemic. UNAIDS recognizes that States impose immigration and visa restrictions as a valid exercise of their national sovereignty. However, in imposing any restrictions on entry and stay relating to HIV or health, UNAIDS calls upon States to adopt non-discriminatory laws and regulations which rationally achieve valid objectives through the least restrictive means possible.
UNAIDS, in collaboration the World Food Programme (WFP) and the World Health Organization (WHO), has developed a policy brief on HIV, food security and nutrition. This policy provides guidance for governments, civil society and other partners on how to address food and nutrition concerns in the context of HIV, keeping in mind the commitment made by all UN member states through the Millennium Development Goals both to reduce chronic hunger and halt and reverse the spread of HIV by 2015.
Based on interviews in two South African provinces and extensive consultation with South African agencies involved with the issue, this report provides a detailed portrait of the situation of rural women, and the interaction among violence, poverty, and the risk of HIV/AIDS. The overview has a concise survey of the development of the AIDS epidemic in South Africa including the debates about government policy and the active role of civil society.
12. Governance and participation in health
It is widely believed that the recent overhaul of WHO’s publication policy is a response to recent pressures from some developed countries that were unhappy with some of its publications on the subject of IP and public health. There are serious concerns that the publications policy presented in the Secretariats Reports will result in 'self censorship' by WHO and its staff and will hamper timely advice and support by WHO HQ and regional offices to member states over important issues such as application of intellectual property rights and the use of TRIPS flexibilities, other trade and health matters, reproductive health care and other issues.
The first African workshop on governance, transparency and accountability processes in access to medicine attracted delegates from 30 civil society organisations in Uganda, Kenya, Zambia and Ghana. The participants benefited from an eight-day training held at Windsor Hotel Entebbe from 17-24 February 2008, ahead of the launch of Medicines Transparency Alliance (MeTA) project in London in May. The MeTA project is a global initiative by the UK Department for International Development (DFID) aiming to use a multi-stakeholder approach towards increasing transparency around the regulation, selection, procurement, sale, distribution and use of medicines in developing countries, thereby strengthening governance, encouraging responsible business practices and ultimately improving access to medicines, especially for the poor. The MeTA project is being piloted in Ghana and discussions are going on for it to be launched in Uganda as well. Funded by DFID, the workshop was hosted by HEPS-Uganda, working in partnership with Health Research for Action (www.herabelgium.com) and Healthlink Worldwide (www.healthlink.org.uk).
In Yumbe District of north-western Uganda, Village Health Teams (VHT) have been established in line with the national strategy for community involvement in health. This paper reviews aspects of the programme outlining its successes and challenges. Its success has been mainly due to integration of pre-existing volunteer cadres, intersectoral approach to the monitoring of the teams and involvement of the community in the selection of the top-up team members. Its challenges include the relatively young age of most volunteers and the likely loss of financial support for the activities of the volunteers. The paper concludes that the VHT programme is a delicate venture requiring both programme support through intersectoral inputs to the Community Action Plans developed by communities and sociological approaches to educate the communities to support the VHT for its sustainability.
13. Monitoring equity and research policy
In countries plagued by socio-economic imbalances inherited from undemocratic systems of government, it is crucial that the products of democratic transition, such as freedom of information legislation, must be used to address imbalances. In the field of socio-economic rights, freedom of information creates a basis for contestation and justification of government decisions on resource allocation. It creates a basis for a fair and reasonable manner of decision-making.
A goal of the health management information system (HMIS) is to provide reliable, comprehensive information about the health system to health managers, to enable them take decisions that will improve the services provided to the consumers. Whereas HMIS quality concerns like the accuracy, completeness and timeliness of reports have been more commonly assessed and reported about in a number of studies, relatively less documentation is found on the actual utilisation of the information generated from HMIS reports. Yet, the HMIS is not an end in itself but just a tool to inform managers and enable them take informed and timely decisions. This study assessed the utilisation of HMIS data for decision making at the grassroots level in Bufumbira East Health Sub-District (HSD) of Kisoro District. It was found that HMIS data were not used for decision making at the point of collection and that the HMIS was dogged by many problems like few dedicated staff. The staff lacked sensitization on the HMIS and were not trained in completing the reports and data analysis. Lower level units submitted their data directly to the district bypassing the HSD. The HMIS was not planned for and lacked funding and stationery. HMIS functioning was not a subject for support supervision and there was only verbal feedback from the district level. It was recommended that the normal flow of HMIS data through the HSD level be re-established and that support supervision on the HMIS be instituted. Planning for the improvement of the system would ultimately lead to its utilisation.
This study was undertaken to describe the performance of health research ethics review procedures of six research centres in Tanzania. Data collection was done through a self-administered questionnaire and personal interviews. The results showed that there were on average 11 members (range= 8-14) in each Research Ethic Committee. However, female representation in the committees was low (15.2%). The largest proportion of the committee members was biomedical scientists (51.5%). Others included medical doctors (19.7%), social scientists (7.6%), laboratory technologists (10.6%), religious leaders (4.5%), statisticians (3.0%), teachers (1.5%) and lawyers (1.5). Committee members had different capacities to carry out review of research proposals. with the majority having moderate and good capacity. Only half of the respondents had prior ethics review training. Although the majority deemed that ethical guidelines were very important, there were challenges in the use of ethical guidelines which included lack of awareness on the national accreditation mechanisms for ethics committee. Adherence to ethical principles and regulations was influenced by being a scientist, being an employee of a professional organisation and having an interest in the use of ethical guidelines. These findings indicate the need for capacity strengthening (through training and resource support), inclusion of more female representation and other mandatory professions to the research ethics committees.
This article proposes a new method for evaluating prevention of mother-to-child transmission of HIV (PMTCT) programmes. The authors suggest that HIV-free survival is the gold standard (or ideal measure) for settings with limited resources. It captures not only HIV infections, as well as deaths prevented, but also the benefits of survival for all children exposed to HIV including those that do not become infected. The authors also propose modifying regular country-wide Demographic and Health Surveys (DHS) by including more detailed questions regarding maternal HIV history, PMTCT programme enrolment and interventions received, infant feeding practices and household child mortality. In sampled households, they advocate the addition of a ‘heel stick’ for dried blood spot collection among children less than two years of age. The authors conclude that modifying the DHS as they propose could provide a reliable method for assessing PMTCT effectiveness which could be used Africa-wide. It would also have the added advantage of including women who have not accessed institutional obstetric care and would otherwise have been excluded from most assessments.
Muhimbili National Hospital (MNH), a teaching and national referral hospital, is undergoing major reforms to improve the quality of health care. Researchers performed a retrospective descriptive study using a set of performance indicators for the surgical and laboratory services of MNH in years 2001 and 2002, to help monitor and evaluate the impact of reforms on the quality of health care during and after the reform process. In 2001, 23.5% of non-emergency operations were planned, while in 2002, 29% were postponed. The most common reasons for operation postponement were 'time-barred', interference by emergency operations, no show of patients and inoperable anaesthetic machines. Equipment problems and supply and staff shortages together accounted for one quarter of postponements. In the laboratory, a lack of equipment prevented some tests, but quality assurance was performed for most tests. Current surgical services at MNH were reported to be inadequate; operating theatres require modern, functioning equipment and adequate supplies of consumables to provide satisfactory care.
This Review addresses a mismatch between what is known about how to respond to particular health problems in poor economies and what is actually done about them. It focuses on one cause of the problems that ensue from the mismatch – capacity constraints. Weak capacity at a number of levels in the institutions and interfaces between knowledge generation and use in policy-making has been identified by the Alliance for Health Policy and Systems Research (HPSR) as a key strategic issue in addressing health care in low-income countries.
The WHO research strategy team has just finished its global consultations towards setting a new focus and role for WHO in health research: leadership and convening power to help other bodies set agendas, and an internal focus on ‘making a difference’ – getting care to where it’s most needed. The strategy is reported to demand impact both internally, within WHO, and externally, to give WHO a global leadership role.
An international group of prominent academics — including several Nobel prize winners — has urged WHO member states to support radically new ways to address the lack of research into diseases that affect the poor. In particular, they are seeking a sizeable increase in government support for research into these diseases through an international research and development fund, and alternatives to the financial incentives of patents.
14. Useful Resources
This resource book is aimed at all who are interested in making Child-to-Child an integral part of their programmes. This revised edition of the widely used Child-to-Child Activity Sheets, includes changes based on WHOs Facts for Life. New activity sheets on bird flu, sexual health and safe motherhood and diabetes are included.
Medecins Sans Frontieres (MSF) has launched a website making its publications available. MSF research has frequently demonstrated pioneering approaches for tackling a broad range of diseases in many countries and, often, has influenced clinical practice. Well-known examples are MSFs pioneering work in treating populations with HIV using antiretroviral medications and malaria with artemisinin-containing treatment. The site has over 350 articles on HIV care, malaria, tuberculosis, leishmaniasis and other diseases, as well as more general topics such as medical care in emergencies, refugee health and health politics.
In support of the implementation of the Kenyan national guidelines on nutrition and HIV/AIDS, this training manual is designed for healthcare service providers working in comprehensive care centres. It aims to equip participants with the knowledge and skills necessary for managing the specific nutritional needs of people living with HIV/AIDS. The provision of methodology, suggested content, materials and further reading allow trainers to formulate a programme specific to their context. The manual includes a variety of tools such as a sample training programme, sample questionnaires, tips on evaluation, guidelines and a step-by-step process for the preparation of sessions, check lists, props and background information on the national guidelines.
This Training Companion is a result of interregional collaboration, based on concepts and illustrative examples from African cities that recently initiated participatory budgeting. The Companion provides visibility and resonance to the efforts that have been made by many anonymous women and men of Latin America to improve democracy and construct participatory governance in their own cities. The interregional collaboration in the preparation of this Companion has also generated a process of mutual learning across language groups and regions in Africa as well as in Latin America. The inputs of the various institutions, including sensitisation events and pilot workshops, underscore the multiple ownership of the publication.
This website provides information on the World Social Forum 2009 in the Amazon. Organisations, networks and movements can obtain and exchange information and help building yet one more edition of the WSF. The website will be updated periodically with information on a set of themes linked to the participation on the 2009 event.
15. Jobs and Announcements
The 12th Triennial Congress will address the enormous challenges and opportunities for public health organizations worldwide to make a difference.
The World Federation of Public Health Associations and the Turkish Public Health Association invite local, national and international public health leaders, advocates and students to submit abstracts dealing with the major cross-cutting sub-themes: education, research, and practice. These abstracts should demonstrate the link between public health education, research, and practice and improved health outcomes. The abstracts should also showcase innovations, practices, tools and transferable lessons from across the globe that will help us make a decided difference in global public health. Submit abstracts in the following general topics: Education in Public Health for 21st Century; Global Public Health Workforce; Public Health & Health Services Research & Technology; Global Governance; Health and Development; Comparative Analysis of Health Systems; Strengthening Global Public Health Systems; Financing Global Public Health; Environmental Safety & Stewardship; Health, Geopolitics, & Public Diplomacy; Public Health, Political Will, & the Public Good. Abstract Submission Deadline is Saturday, 5 July 2008, Midnight Pacific Time.
This photography contest has a total of R5 000 in prizes to be won and the winning photograph will appear on the cover of the 2008 South African Health Review (SAHR). Furthermore, the top 10 photographs will be showcased at the official launch of the SAHR in November 2008. The contest is open to students currently enrolled in a Photography, Arts or related area Department (i.e. tertiary institution) in South Africa. Entries must be accompanied by a copy of a valid student ID and by the name of your school and instructor. Photographs must be high-quality prints and can be colour or black and white. Photographs will become property of HST, which retains rights to publish photographs in future publications, and will not be returned. The deadline for submitting entries is 5 September 2008.
The Southern Africa Trust is seeking a consultancy to undertake an assessment of the impact of financial aid flows on the policy work of regional civil society in Southern Africa as part of its ongoing work to engage with donors on financial aid flows to Southern Africa but also as a way of strengthening its work around supporting increased aid flows to civil society for them to be able to effectively to influence policy to overcome poverty. Expressions of interest must be submitted by 28 May 2008, 15.00pm
The Health Systems Action Network (HSAN) invites you to apply to join its membership and become a part of a global voice for Health Systems Strengthening. HSAN is a volunteer grassroots-level global network of developing country professionals committed to strengthening health systems through effective involvement of diverse stakeholders, spreading of actionable knowledge, and better management of resources that is guided by evidence. HSAN´s emphasis is to increase access to information on effective strategies that work to strengthen health systems, and to avoid implementation of strategies that have been found to be less effective in strengthening health systems. HSAN aims to provide a platform for voices from developing countries, and fill the gaps that exist in effectively addressing HSS issues at the national, regional, and global levels by establishing partnerships at each level. If you have strong health systems experience, you are encouraged to apply and the selection committee will then invite those screened and accepted as full members.
Writers and journalists are invited to submit articles for a 44-page magazine for the Global Ministerial Forum on Research for Health in Bamako later this year, with support from IDRC (Canada), on the connection - or lack of connection - between research for health, health policy-making, and health action, mainly (but not entirely) in Africa. Article proposals should be submitted immediately and articles must be submitted by latest, end July 2008.
The 2008 high-level meeting on AIDS will take place at the United Nations headquarters in New York on 10-11 June. It will review progress made in implementing the 2001 Declaration of Commitment on HIV/AIDS and the 2006 Political Declaration on HIV/AIDS. The high-level meeting will provide an important forum for various stakeholders, including government representatives and accredited civil society participants. Discussions are expected to focus on the progress made, challenges remaining and sustainable ways to overcome them.
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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