On 28 May 2008, the Institute of Tropical Medicine (ITM, Antwerp) hosted a workshop at the World Health Organization (WHO, Geneva) to review the evidence on positive and negative impacts of the global AIDS response in low-income countries in sub-Saharan Africa on general health systems and services. The workshop involved people working in AIDS and health services, in civil society and in academia with and from Sub-Saharan Africa.
The original question was simple and straightforward: what is the evidence to support or refute recent claims that global resources allocated to fight AIDS are over inflated and do little to support, and may even undermine, health systems?
Discussions quickly moved beyond this original question. The Alma Ata concept of Primary Health Care (PHC) – comprehensive PHC rather than selective PHC – proved to be a uniting concept. The real question became: how can the global AIDS response best contribute to the realisation of Comprehensive PHC? Most participants agreed that there are lessons to be learned – good and bad – from the global AIDS response, that will help us move closer towards Comprehensive PHC for all.
There is evidence of the global AIDS response strengthening general health systems and services, and there is also evidence of the global AIDS response weakening general health systems and services.
The most important point of stress identified related to the overall shortage of health workers. In some countries, the AIDS response was reported to have led to an ‘internal brain drain’, with health workers abandoning their previous occupations to work on AIDS programmes. In other countries, the AIDS response enabled improved working conditions of health workers across the board, helping to attract and or retain more health workers.
Without systematic reviews, or an agreed score card allowing us to add up the strengthening effects and to subtract the weakening, we cannot conclude if the overall result is predominantly negative or positive. However, the positive effects of strengthening general health systems and services seem be more likely where national public sector led strategies explicitly aimed for these positive synergies. This finding suggests that if recipient countries want AIDS funding to strengthen general health systems and services, they need to negotiate the needed flexibility from donors for this.
Therefore, we felt it would be more productive to focus on what measures promote positive synergies and avoid negative synergies - to support this, rather than trying to make a conclusive statement on whether the balance is currently positive or negative.
One key issue is the under-funding of health care in developing countries. Whether the objective is Comprehensive PHC for all, fulfilling the Right to Health obligation, or achieving the health-related Millennium Development Goals (MDGs), neither national nor international funding of health care measures up.
Scarcity of human and financial resources was observed to drive competition and rivalry. At the same time, health funding should not only increase, but also become more reliable in the long run. For ministries of health to embark to an ambitious health workforce programme, for example, a long term financing perspective is needed. It doesn’t make sense to increase training capacity today, if 10 years from now the additional health workers’ salaries cannot be secured to employ trained personnel. A new concept of sustainability adopted for AIDS treatment – where sustainability is based on domestic resources and sustained international funding – should be expanded to health systems and services, including salaries of health workers.
Most participants to the meeting acknowledged that AIDS activists have been more successful than the proponents of PHC at getting their priority high on the political and funding agendas. However, within the spirit of Comprehensive PHC, they saw this could be an opportunity rather than a threat, if this is used to equally raise the profile on general health systems and services, not to depress the profile given to AIDS responses.
Delegates felt the means to this was through renewed impetus for what is fundamentally a shared and uniting paradigm of Comprehensive PHC, including AIDS prevention and treatment, where:
• Health (and health care) is a human right, and an entitlement
• Programming and financing is adapted to needs and not to scarcity of human and financial resources
• Macroeconomic policies are adjusted to vital needs and not the other way around
• Concerns about the sustainability of health care is addressed as a shared global responsibility, depending as much on sustained national funding as on sustained international funding
• The people whose health is at stake are involved in the decision-making process
Where the global AIDS response has made significant progress on these issues, the benefits of this progress must be extended to general health systems and services.
Therefore:
• Governments must live up to their promises: governments of low-income countries must allocate 15% of their domestic government revenue to health while governments of high-income countries must allocate the equivalent of 0.7% of their Gross Domestic Product (GDP) to global solidarity, and 15% of that (0.1% of GDP) to health.
• These commitments should be open-ended (as long as needed), without aiming for national financial resources to replace international financial resources as soon as possible, as this would undermine the crafting of ambitious health plans, including workforce plans.
• Ceilings on health expenditure (included in policies imposed by the International Monetary Fund) must not hamper the realisation of the right to health or Comprehensive PHC for all.
• The people whose right to Comprehensive PHC is at stake have the right and the duty to be involved in critical decisions that affect their health.
• The global aid architecture must be reorganised in such a manner that it supports Comprehensive PHC for all, not one part of Comprehensive PHC at the expense of another; andGeneral health systems and services not only need strengthening, but also transforming: involving and working with communities as participants of health systems and services, rather than merely ‘clients’ or passive recipients of health services.
We found that the global AIDS response created real challenges for health systems and services, but also that there are ways to tackle and minimise them. The global AIDS response also created real opportunities, which should be maximized.
Comprehensive PHC is a uniting goal for all constituencies. It demands a significant mobilisation of knowledge, experience and additional funding. We cannot afford to repeat the mistake of three decades ago, when the ideal of Comprehensive PHC was abandoned as unaffordable, leaving us with the present health and health systems deficit.
This oped is not intended to be an accurate record of the meeting referred to which can be obtained from the authors located at Institute of Tropical Medicine, Antwerp [http://www.itg.be/itg/GeneralSite/Generalpage.asp]. EQUINET welcomes further opeds on the issues raised in this oped and on Comprehensive PHC, particularly from an equity perspective. Please send debate, comment or queries on the issues raised, or communications for oped authors to the EQUINET secretariat, email admin@equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
This study aimed to assess equity in uptake of antiretroviral therapy in Malawi in 2005, especially according to age (children vs. adults), gender (men vs. women) and income. Particular reference is made to the scaling up of ART and the removal of fees for ART in 2004. Informal interviews were conducted with health sector antiretroviral programme implementers and key policy makers in the Ministry of Health. The researchers also searched both published and grey literature to collect information on the history and operations of the Malawi public sector-led ART programme. Retention rates remain high in Malawi's ART programmes (84%), which compare favourably with those elsewhere on the continent. Rates ranging from 44% to 85% of people remaining on treatment after 24 months of treatment have been reported in ART programmes throughout Africa (Rosen et al, 2007). While there were some reports from key informants that the change from fee-paying ART services to free systems may have improved patient adherence to treatment regimes, the research did not provide conclusive evidence of the impact of cost of patients' medications on their adherence to their treatment regimens. Different adherence rates in different areas and programmes suggest that other determinants may be affecting affect this outcome.
In Uganda, community-based health insurance started in 1995; however, the number of schemes has remained small with very low coverage levels. This study examines issues of equity and sustainability in these prepayment schemes; if they are to contribute significantly to health sector financing, the schemes must be equitable and sustainable. A descriptive cross-sectional study employing qualitative techniques was carried out. Key informant interviews, focus group discussions and documents review were used. Data was tape-recorded, transcribed, typed, manually analysed thematically using a master sheet. Abolition of user fees did not have a big effect on enrolment into the schemes. People went for higher quality services, which were perceived to be provided in private health facilities rather than government services. Schemes were perceived to directly contribute towards health financing by providing funds for the procurement of drugs and equipment, allowing people to contribute to their own health care. An indirect benefit is that they would ease the pressure on public facilities by diverting patients from the public health sector. Whereas some thought the contribution of CHI schemes was insignificant due to low enrolment, others felt the schemes needed to be strengthened to build confidence in social health insurance. The researchers recommend that government increase funding to maintain the improvement in quality of health care in public facilities. Future health policy needs to address whether or not CHI has a role to play in the Ugandan context and in institutionalising SHI.
African Heads of State committed themselves at a meeting in Abuja in 2001 to devoting a minimum of 15% of government funds to the health sector in order to address the massive burden of ill-health facing countries in Africa, particularly within the context of a growing burden of HIV, AIDS, TB and malaria, This report considers progress towards this target and is based on information provided by researchers in seven east and southern African countries. Of the countries reviewed, only Zambia and Malawi have made considerable progress towards the Abuja target, with the health sector’s share of total government expenditure increasing consistently from 8% and 5% respectively in 1997 to nearly 11% and 7% in 2000 and almost 18% and 11% in 2003 (thus exceeding the Abuja target in the case of Zambia). Although Namibia has not achieved the Abuja target, it has made good progress from 10% in 1997 to nearly 14% in 2003. Kenya is the furthest from the Abuja target, with only 5% of government resources going to health services in 2006 and with no consistent increase in government spending. Some seven years after the Declaration, many countries are still lagging well behind the target, although there are promising signs of increases in allocations towards the health sector in some.
This report presents a review of the public health laws in Kenya, Uganda and Tanzania that impact on equity in health, to assess the extent to which the current legal framework addresses public health and health equity. Public health law has perhaps not had adequate profile in academic and professional practice, but is a critical area of work if countries in east and southern Africa are to protect public health and health equity in an environment increasingly influenced by global challenges and policies. Various areas of law are provided for in all countries, and it is more in their application that there may be deficits. Some areas of law are provided for in some laws but not in all relevant laws, or not in all countries. This calls for measures to harmonise the legal frameworks within countries to ensure consistency, and across the three countries to protect health across the region as a whole. In some cases there are policy commitments but omissions or gaps in law to reflect these policy commitments and ensure their application at national level across all sectors. The authors suggest that these areas be reviewed by health authorities, parliamentary committees, health professional associations and health civil society.
In the study, the researchers explore how policies are shaped and transformed in the process of implementation, using as a case study the implementation of two community health workers policies in a rural sub-district in South Africa. The researchers investigated how role players at different levels of the implementation process interacted with each other and the policy and how they used power at their disposal in this process. Rather than focusing on the gap between policy formation and policy outcome, with implementation being a mere administrative follow-on, the researchers took a 'bottom-up' perspective, which allows one to view implementation as an integral and continuing part of the policy process. Within this, the researchers particularly explored the use of discretionary power by front-line implementers, finding that selective communication and lack of information led to a 'thinning down' of a complex and comprehensive policy. While ftontline implementers did not have the power to change the rules that were set by the provincial actors, they used their knowledge of local conditions, control over local knowledge and distance from the provincial capital to shape implementation at the service level.
Very few east and southern African countries have health care spending levels anywhere near the 2001 WHO recommended US$80 per person per year. In 2001 in Abuja African heads of state committed to allocating 15% of government budgets to health -- the Abuja declaration. This brief shows that several countries (Malawi, Namibia, Zambia, Uganda) have made considerable progress in increasing domestic funding, towards the Abuja target. It outlines evidence to argue that devoting 15% of domestic public funds to the health sector is necessary – both to address the health and health care needs within east and southern Africa (ESA) and to ensure progress towards building a universal and comprehensive health system. The target of 15% is not unrealistic – it is very much in line with levels of public spending in other countries around the world Achieving the 15% target demands that public funds not be consumed by debt servicing, so rapid implementation of debt cancellation is critical. The 15% is understood to mean domestic public spending on health, excluding external funding. It should be regularly monitored and publicly reported by governments. Even if countries achieve the 15% target, for many there will still be a substantial gap in funding for health services. More resources flow out of Africa than into the continent, so sustainable health financing demands global solidarity. External funding support is thus critical, based on OECD countries’ commitment to contribute 0.7% of their GNP as official development assistance (ODA). Increased spending on health services should not be at the expense of spending on other social services, as this is fundamental to promoting human development, so that people benefit from and contribute to economic development.
3. Equity in Health
This is the interim position paper of the People's Health Movement (PHM). The comprehensive Primary Health Care (PHC) approach articulated at Alma Ata remains as relevant today as it was 30 years ago. It was never really implemented to reflect its true spirit, i.e. the basic intent of the Alma Ata Declaration which highlighted the need for a new international economic order to ultimately solve inequities in health. A PHC policy for 2008 and beyond needs renewed commitment, which, while affirming the fundamental positions of thirty years back, also takes into account the new realities of this age. In its renewed commitment to PHC in 2008, PHM vies to address the obstacles that have blocked PHC's implementation so far and is furthermore committed to incorporate into it the new challenges that have emerged since 1978. PHM is committed to promote the still unshaken basic principles of the Alma Ata Declaration - way beyond its original eight technical components. PHM insists that PHC is to be embedded in the social and political processes in each specific context where it is applied.
Most countries do not have universal health insurance and for most people living in countries without universal access, particularly the poor, illness is a substantial financial burden, and indeed often a crippling burden. Paradoxically, a far greater proportion of out-of-pocket spending occurs in those countries least able to afford it. Inevitably, health care, far from being a basic human right, is simply beyond the reach of many. These problems are magnified in lower- and middle-income countries. For example, in Tanzania a 1997 scheme to implement evidence based health plans at an estimated cost of US$2 per capita was limited by inadequacy of infrastructure and capacity. These difficulties are particularly evident where there is increased spending on vertical programmes in areas of limited capacity and infrastructure, limiting resources available to the system as a whole. In light of this, this article highlights some key questions for tackling equity in health, including: 1) What do we mean by equity? Which aspect has primacy -dollars spent or health status or health outcomes? 2) How do we determine what is a reasonable amount to spend (or invest)? How can this best be contextualised and harmonised with other government priorities? 3) Would there be more equitable access to health services if governance and decision-making were more open to input by community stakeholders? 4) Given the resource and other infrastructure constraints, particularly in poorer countries, what are the most appropriate health care delivery models for a country to adopt?
The objective of this study was to quantify inequalities in selected Millennium Development Goal (MDG) indicators in all the 192 WHO Member States using descriptive statistics, the Gini coefficient and the Theil coefficient. The data on all the indicators were obtained from The World Health Report 2004. The main findings were as follows: (i) generally, all the MDG indicators are significantly worse in low-income countries than in the other three income groupings; (ii) for all the MDG indicators, there are inequalities within individual countries, within the four income groups, and across income groups of countries; (iii) the inequalities in the MDG indicators are higher among the low-income countries than in high-income countries; and (iv) the ranking of income groups, by various indicators, is fairly stable whether one employs the Gini coefficient or Theil coefficient. Member States striving to expand the effective coverage of heatlh strategies and interventions need to do this in a manner that redresses the inequalities in various MDG indicators, and to monitor aggregate changes in MDG indicators and inequalities across the various income quintiles. The lessons learnt from the monitoring should inform the design and targeting of MDG-related policies, strategies and interventions to eradicate inequalities.
The under-five mortality (U5MR) rate in South Africa in 1990 was 60. South Africa needs to achieve an U5MR of 20 by 2015 to meet its Millenium Development Goal target. Yet, in contrast to most countries, the U5MR in South Africa is rising rather than declining. Based on current trends, unless urgent measures are taken to address the main causes of death, South Africa has little hope of reaching the MDG target. To inform intervention, this article undertakes a critical examination of the determinants of under-5 mortality.
The International Conference on Primary Health Care and Health Systems in Africa, meeting in Ouagadougou, Burkina Faso, from 28 to 30 April 2008, reaffirms the principles of the Declaration of Alma-Ata of September 1978, particularly in regard to health as a fundamental human right and the responsibility that governments have for the health of their people. Having analysed the experience of Primary Health Care implementation in the countries of Africa in the last 30 years, the Conference expresses the need for accelerated action by African governments, partners and communities to improve health. The Conference also reaffirmed the importance of the involvement, participation and empowerment of communities in health development in order to improve their well-being, as well as the importance of a concerted partnership, in particular, between civil society, private sector and development partners, to translate commitments into action.
4. Values, Policies and Rights
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.
Two hundred and five African and global organisations and networks have called on the Assembly of Heads of State of the African Union to ensure the Implementation Plan of the AU Africa Health Strategy is urgently and adequately funded, and for the AU Abuja 15% Commitment to health to be implemented by all member states. The Implementation Plan was adopted by African Ministers of Health on the 17th of May 2008 following presentation of the Health Strategy in 2007 by the AU Commission Social Affairs Division. It provides guidelines for implementing various African health frameworks, health MDGs and global Universal Access targets including on TB, HIV and AIDS, Malaria, Child and Maternal Health. The Health Strategy Implementation Plan will be presented for final approval to the Assembly of Heads of States meeting in Sharm El Sheikh, Egypt on the 30 June and 1 July. In a statement on the eve of the Assembly, Rotimi Sankore Coordinator of the Africa Public Health 15% Now Campaign stated:
"The AU Africa Health Strategy is a landmark document. But without funding for its Implementation Plan from our Heads of State and Finance Ministers, it will be reduced to an empty gesture resulting in even more deaths than the current 8 million African lives lost annually to mainly five health conditions being TB, HIV and AIDS, Malaria, Child and Maternal Mortality."
The Compendium of key documents relating to human rights and HIV in Eastern and Southern Africa is a collection, in five parts, of global, regional, sub-regional and national human rights instruments, policies, legislation and case law that are relevant to HIV and AIDS. In most instances, only excerpts pertinent to HIV and AIDS are provided. When applicable, reference is made to a source where the full text may be accessed.
This bill is intended to amend the Medical Schemes Act, 1998, so as to provide for risk equalisation among medical schemes; to amend and insert certain definitions; to provide for the establishment of a risk equalisation fund; to extend the functions of the Council for Medical Schemes in relation to risk equalisation; to provide for the application of risk equalisation to medical schemes; to provide for the provision of information by medical schemes to the Council for Medical Schemes for purposes of risk equalisation; to provide for the methodology and procedures for risk equalisation; to amend the provisions relating to benefits and contributions provided by medical schemes; to amend the provisions relating to the composition of boards of trustees and eligibility of persons to serve as trustees or principal officers; to define the respective functions of boards of trustees and principal off key to specify the powers of the High Court in relation to election processes; to amend the provisions relating to disclosure of trustee remuneration; to provide for good corporate governance guidelines and associated disclosure requirements; to amend the provisions relating to the powers of the Minister to make regulations; to amend the provisions relating to offences; to rearrange some of the existing sections; and to provide for matters in connection therewith.
This bill is intended to amend the Medicines and Related Substances Act, 1965, so as to provide for the establishment of the South African Health Products Regulatory Authority; for the certification and registration of products which include medicines, medical devices and certain foodstuffs and cosmetics, for the control of scheduled substances; and matters incidental thereto.
This bill is intended to amend the Medicines and Related Substances Act, 1965, so as to provide for the establishment of the South African Health Products Regulatory Authority; for the certification and registration of products which include medicines, medical devices and certain foodstuffs and cosmetics, for the control of scheduled substances; and matters incidental thereto.
Two bills recently tabled in the South Africa Parliament are set to shake up the private hospital industry and centralise decision-making over hospital tariffs as well as the regulation of new medicines and scientific trials within the health minister’s office. The National Health Amendment Bill (health bill) and the Medicines and Related Substances Amendment Bill (medicines bill) were both published in April and there is widespread agreement that they are the most important pieces of health legislation to be proposed in recent years. The article presents the changes and the debate around the bills.
Among the questions raised at the WHO's 123rd Executive Board meeting were the need and rationale for the new publications policy, what the present policy is, and what will be the criteria for determining which issues have "policy implications for the Organisation" and which comprise "controversial health related issues" and thus have to go through additional clearance by the Director-General's Office. Other concerns raised included how the centralisation of the clearance process may remove the clearance authority of the WHO's regional directors, the broad definition of the term "publications" as it covers "materials that are issued by WHO to the public in whatever format and through whatever channel" including advocacy and training materials, how the policy will affect timely support by WHO to countries, and concerns about "self-censorship" as a result of the policy and transparency in the process.
5. Health equity in economic and trade policies
This report is the last in a series from NEF designed to stimulate progress towards a comprehensive and fair treatment of the crisis of sovereign debt. With the end of an unprecedented period of low interest rates now in sight, such a goal is needed more than ever. Debt relief isn’t working. Current approaches (HIPC and MDRI for poor countries and Paris and London Club renegotiations for middle-income countries) are not solving the problems of Third World indebtedness. HIPC and MDRI are indeed reducing debt burdens, but for a small range of countries, and at a high cost in terms of loss of policy space and after long delays, but non-HIPC poor countries also have major debt problems. Middle-income countries’ indebtedness continues to grow. There is a clear need for a new approach to resolving sovereign debt problems that is comprehensive, systematic, fair and transparent and above all, just. Responses from the creditors so far to criticisms such as those in the previous paragraph have been grossly inadequate. There is as yet no consensus about the way forward. This report aims to stimulate debate and help find a just solution to the debt crisis.
The International Monetary Fund no longer has the financial clout to fulfil its traditional role of lending out money to save crisis-stricken countries, according to a Bank of England report. In all cases the analysis suggests the present IMF lending framework may no longer be appropriate. The working paper is unique because most critics of the Fund have instead focused on the shortcomings of its management structure or economic analysis. It said that the Fund "is increasingly unlikely to provide financing on a sufficiently large scale to meet the demands of higher-risk members." The IEO report also urged the Fund to overhaul its governance structure, much of which is largely unchanged since the 1940s. Among its recommendations was a call to reform the selection process for managing director.
The International Monetary Fund (IMF) has approved a three-year, US$79-million plan to support Zambia's efforts to alleviate poverty and sustain economic growth. The new Poverty Reduction and Growth Facility (PRGF) plan succeeds a previous arrangement successfully completed last year, the IMF said in a press release. The new PRGF arrangement will support the government's objectives of boosting economic growth and enhancing employment and income opportunities, especially for the poor, while maintaining macroeconomic stability. The PRGF is the IMF's concessional facility for low-income countries. PRGF loans carry an annual interest rate of 0.5 percent and are repayable over 10 years with a five-and-a-half-year grace period on principal payments.
The Regional Economic Communities (RECs) are the pillars of the African Union (AU), and have been recognised by the AU as the key vehicles for economic integration and cooperation in Africa. The 2003 Session of the AU Conference of African Ministers of Health (CAMH) considered and adopted, inter alia, recommendations on a proposal to establish Health and Social Affairs Desks within the RECs. The 2003 Maputo Session of the Assembly of AU Heads of State and Government duly endorsed the Report of the Ministers and their recommendations. This paper represents an attempt to assess the extent to which the 2003 decision of CAMH has been implemented. The researchers also argue that regional integration and cooperation should not be geared solely towards economic, trade or political purposes but to the social sector as well, and proposes a set of criteria as useful starting points for determining which social (i.e. health) activities can be undertaken at the regional and sub-regional levels.
6. Poverty and health
Malnutrition is a serious public health problem, particularly in developing countries, linked to a substantial increase in the risk of mortality and morbidity. Women and young children are most often affected. Rural disadvantage is a known factor, but little attention has been paid to rural-urban disparity among women. To provide a reliable source of information for policy-makers, the current study used nationally representative data from 26 countries in sub-Saharan Africa to update knowledge about the prevalence malnutrition and its rural-urban disparities among women. The data sources were the demographic and health surveys of 26 countries conducted between 1995 and 2006.Overall, rural women were 68% more likely to be malnourished compared with their urban counterparts.
With increasing urbanization in sub-Saharan Africa and poor economic performance, the growth of slums is unavoidable. About 71% of urban residents in Kenya live in slums. Slums are characteristically unplanned, underserved by social services, and their residents are largely underemployed and poor. Recent research shows that the urban poor fare worse than their rural counterparts on most health indicators, yet much about the health of the urban poor remains unknown. This study aims to quantify the burden of mortality of the residents in two Nairobi slums, using a Burden of Disease approach and data generated from a Demographic Surveillance System. Data from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) collected between January 2003 and December 2005 were analysed. Core demographic events in the NUHDSS including deaths are updated three times a year; cause of death is ascertained by verbal autopsy and cause of death is assigned according to the ICD 10 classification. Years of Life Lost due to premature mortality (YLL) were calculated by multiplying deaths in each subcategory of sex, age group and cause of death, by the Global Burden of Disease standard life expectancy at that age. The overall mortality burden per capita was 205 YLL/1,000 person years. Children under the age of five years had more than four times the mortality burden of the rest of the population, mostly due to pneumonia and diarrhoeal diseases. Among the population aged five years and above, HIV/AIDS and tuberculosis accounted for about 50% of the mortality burden. Slum residents in Nairobi have a high mortality burden from preventable and treatable conditions. It is necessary to focus on these vulnerable populations since their health outcomes are comparable to or even worse than the health outcomes of rural dwellers who are often the focus of most interventions.
The Afrobarometer has developed an experiential measure of lived poverty called the Lived Poverty Index (LPI). It measures how frequently people go without basic necessities during the course of a year. This is a portion of the central core of the concept of poverty not captured by existing objective or subjective measures. As an individual measure, the LPI is found to be valid and reliable. However, it exhibits only moderate external validity when compared with absolute measures of national wealth. Contrary to what appears to be the consensus among economists, GDP growth is accompanied by increases in lived poverty, and there is only a weak relationship between LPI and measures of human development or income poverty. At the same time, lived poverty is strongly related to country level measures of political freedom. This supports Sen's (1999) arguments about development as freedom and Halperin et al’s (2005) arguments about the “democracy advantage” in development. This paper concludes that this measure does well at measuring the experiential core of poverty, and capturing it in a way that other widely used international development indicators do not.
7. Equitable health services
Although evidence-based interventions to reach the Millennium Development Goals for Maternal and Neonatal mortality reduction exist, they have not yet been operationalised and scaled up in Sub-Saharan African cultural and health systems. A key concern is whether these internationally recommended practices are acceptable and will be demanded by the target community. The researchers explored the acceptability of these interventions in two rural districts of Uganda; conducted ten focus group discussions consisting of mothers, fathers, grand parents and child minders (older children who take care of other children); and ten key informant interviews with health workers and traditional birth attendants. Most maternal and newborn recommended practices are acceptable to both the community and to health service providers. However, health system and community barriers were prevalent and will need to be overcome for better neonatal outcomes. Pregnant women did not comprehend the importance of attending antenatal care early or more than once unless they felt ill. Women prefer to deliver in health facilities but most do not do so because they cannot afford the cost of drugs and supplies which are demanded in a situation of poverty and limited male support. Postnatal care is non-existent. For the newborn, delayed bathing and putting nothing on the umbilical cord were neither acceptable to parents nor to health providers, requiring negotiation of alternative practices. Communities associate the need for antenatal care attendance with feeling ill, and postnatal care is non-existent in this region. Health promotion programs to improve newborn care must prioritise postnatal care, and take into account the local socio-cultural situation and health systems barriers including the financial burden. Male involvement and promotion of waiting shelters at selected health units should be considered in order to increase access to supervised deliveries. Scale-up of the evidence based practices for maternal-neonatal health in Sub-Saharan Africa should follow rapid appraisal and adaptation of intervention packages to address the local health system and socio-cultural situation.
Maternal mortality is a major health problem concentrated in resource-poor regions. Accurate data on its causes using rigorous methods is lacking, but is essential to guide policy-makers and health professionals to reduce this intolerable burden. The aim of this study was to accurately describe the causes of maternal death in order to contribute to its reduction, in one of the regions of the world with the highest maternal mortality ratios. The researchers conducted a prospective study between October 2002 and December 2004 on the causes of maternal death in a tertiary-level referral hospital in Maputo, Mozambique, using complete autopsies with histological examination. In this tertiary hospital in Mozambique, infectious diseases accounted for at least half of all maternal deaths, even though effective treatment is available for the four leading causes, HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis. These observations highlight the need to implement effective and available prevention tools, such as intermittent preventive treatment and insecticide-treated bed-nets for malaria, antiretroviral drugs for AIDS, or vaccines and effective antibiotics for pneumococcal and meningococcal diseases. Deaths due to obstetric causes represent a failure of health-care systems and require urgent improvement.
Malaria is one of the main reasons why people use health services in sub-Saharan Africa, placing a considerable burden on primary health care. The Affordable Medicines Facility-malaria (AMFm) is a supply-side intervention designed to reduce malaria mortality by improving the availability and affordability of effective treatment. It also aims to delay the development of drug resistance through the use of artemisinin, in combination with other medicines, rather than as a monotherapy. Access to artemisinin-based combination therapies by people living in poverty – those without public facilities and unable to afford artemisinin-based combination therapies at subsidised prices – is a concern. The AMFm will support an enhanced public sector and NGO distribution of artemisinin-based combination therapies, often without charge but supplementary initiatives at PHC level, such as home-based management of malaria, will still be needed.
Directly Observed Treatment Short course strategy (DOTS) has proved to have potential improvement in tuberculosis (TB) control in Tanzania. The objective of this cross sectional study was to assess the capacity of health facilities in implementing DOTS, in Arumeru and Karatu districts, Tanzania. Information sought included the capacity to offer TB service and availability of qualified staff and equipment for TB diagnosis. Information on availability and utilization of TB registers and treatment outcome for the year 2004 were also collected. A total of 111 health facilities were surveyed, 86 (77.5%) in Arumeru and 25 (22.5%) in Karatu. Only 23.4% (26/111) facilities were offering TB treatment services in the two districts. Majority 17/26 (65.38%) of them were government owned. Thirty eight (44.7%) facilities were offering TB laboratory services. All facilities with TB services (TB laboratory investigation and treatment) had TB registers. Seventy two (85.0%) of health facilities which do not provide any TB services had qualified clinical officers and at least a microscopy. Of the 339 cases notified in Arumeru in 2004, 187 (60.7%) had treatment outcome available, 124 (66.3%) were cured and 55 (29.4%) completed treatment. In Karatu 638 cases were notified in 2004, 305 (47.8%) had treatment outcome available, 68 (22.3%) cured and 165 (54.1%) completed treatment. In conclusion, the overall capacity for implementing DOTS among the facilities surveyed is found only in about 20% and 30% for clinical and laboratory components of DOTS, respectively. The capacity to provide TB diagnosis and treatment in Karatu district was relatively lower than Arumeru. It is important that capacity of the facilities is strengthened concurrently with the planned introduction of community- based DOTS in Tanzania.
This research paper reviews individual case histories of children who have died of pneumonia in rural Uganda and investigates why these children did not survive. The research was conducted in the Lganga/Mayuge region in Uganda, where 67,000 people were visited once every three months for population-based data. Children aged 1-59 months from November 2005 to August 2007 were included in the study. The paper finds that of the pneumonia deaths that were registered, half occurred in hospital and one-third at home. Median duration of pneumonia illness was seven days, and median time taken to seek care outside the home was two days. Most children first received drugs at home: 52% antimalarials and 27% antibiotics. The paper concludes that many children with fatal pneumonia experienced mistreatment with antimalarials, delays in seeking care and low quality of care. To improve access to and quality of care, the feasibility and effectiveness of training community health workers and drug vendors in pneumonia and malaria management with prepacked drugs should be tested.
With a view to developing health systems strategies to improve reach to high-risk groups, this research has been conducted on health and survival from household and health facility perspectives in five districts of southern Tanzania. The researchers documented availability of health workers, vaccines, drugs, supplies and services essential for child health through a survey of all health facilities in the area. The researchers conclude that relatively short distances to health facilities, high antenatal and vaccine coverage show that peripheral health facilities have huge potential to make a difference to health and survival at household level in rural Tanzania, even with current human resources.
This study was carried out in Ilala and Kinondoni Municipalities in Tanzania to explore the perceptions of Tuberculosis (TB), and treatment seeking behaviour, among patients attending healthcare facilities. The study was conducted in four randomly selected health facilities providing directly observed treatment (DOT). Exit interviews were administered to 69 randomly selected TB patients. Fifty-nine (84.1%) patients had good knowledge on the transmission of TB. The majority (75%) of the respondents were of the opinion that the incidence of TB was on the increase mainly due to the AIDS epidemic. All respondents knew that TB was a curable disease if one complies with the treatment. Sixty-four (60%) respondents had good knowledge on the correct duration of tuberculosis treatment. The median duration before seeking treatment from a health facility was 1.5 months. The majority of the patients 47 (68%) visited public health facilities for treatment as their first action. Overall, 83.8% respondents said females comply better with treatment than male patients. The majority of the respondents lived within a walking distance to a healthcare facility. Most of the respondents said they were well attended by service providers. Half and 59.3% of the males and females, respectively, mentioned good patient-service provider relationship as an important reason for satisfaction of the service. Twenty-nine respondents were of the opinion that female TB patients conformed better to treatment than males and a similar number thought that both of them equally conformed to treatment. Findings from this study indicate that a large population in urban settings are aware that health facilities play a major role in TB treatment. There is a need to further explore how this information could potentially be used to enhance early seeking of appropriate services among TB patients in the era of rapid urbanization. Strategies in the control of TB and other diseases should focus on advocacy in seeking appropriate care.
This report presents finding of a nationwide Expenditure Tracking and Service Delivery Survey in Mozambique from August to Ocotober 2002. The study focuses on the primary health care system, which is often the only source of health care for most Mozambicans. The data offers a unique perspective on interactions between different levels of the health system, particularly related to financing, allocation, distribution and use of resources. The report covers a broad set of issues including institutional context, budget managemet, cost recovery, drug allocation and distribution, human resources, infrastructure and equipment, and service outputs.
Inadequate levels of immunisation against childhood diseases remain a significant public health problem in resource-poor areas of the globe. Nonetheless, the reasons for incomplete vaccination and non-uptake of immunisation services are poorly understood. This study aimed at finding out the reasons for non-vaccination and the magnitude of missed opportunities for vaccination in children less than two years of age in a rural area in southern Mozambique. Mothers of children under two years of age (N = 668) were interviewed in a cross-sectional study. The Road-to-Health card was utilised to check for completeness and correctness of vaccination schedule as well as for identifying the appropriate use of all available opportunities for vaccination. The chi-square test and the logistic regression were used for statistical analysis. The researchers found that 28.2% of the children had not completed the vaccination program by two years of age, 25.7% had experienced a missed opportunity for vaccination and 14.9% were incorrectly vaccinated. Reasons for incomplete vaccination were associated with accessibility to the vaccination sites, no schooling of mothers and children born at home or outside Mozambique. Efforts to increase vaccination coverage should take into account factors that contribute to the incomplete vaccination status of children. Missed opportunities for vaccination and incorrect vaccination need to be avoided in order to increase the vaccine coverage for those clients that reach the health facility, specially in those countries where health services do not have 100% of coverage.
This paper highlights and promotes the enormous potential that exists between these two initiatives that seek to address closely related issues and targeting the same populations at risk within a fairly well defined geographical setting. It also attempts to argue that malaria control, just like HIV-Aids control be given high priority in the New Partnership for Africa's Development (NEPAD) health agenda, as current statistics indicate that malaria is again on the rise. While much attention and billions of dollars have rightly been given to HIV and Aids research, treatment and prevention, malaria, and not Aids, is the region's leading cause of morbidity and mortality for children under the age of five years. This is the bad news. The good news is that unlike Aids, malaria treatment and prevention are relatively cheap. In addition, there is a payback to fighting malaria; support aimed directly at improving health, rather than poverty reduction, may be a more effective way of helping Africa to thrive. Robust and sustained growth may come to Africa through a mosquito net, Artemisinin-based Combination Therapies (ACTs) or a malaria vaccine, rather that a donor's cheque for economic development initiatives.
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8. Human Resources
The growing gap between the supply of health care professionals and the demand for their services is recognised as a key issue for health and development worldwide. Policy-makers, planners and managers continue to seek effective means to recruit and retain staff. One way to achieve this is to develop and implement effective incentive schemes. The World Health Organization report Working together for health (2006a) estimated a global shortage of 4.3 million health workers, including 2.4 million physicians, nurses and midwives. Translated into access to care, the shortage means that over a billion people have no access to heath care. Many countries are affected by the shortage and 57 have been identified as ‘in crisis’. An effective workforce strategy will address the three core challenges of improving recruitment, improving the performance of the existing workforce, and slowing the rate at which workers leave the health workforce. Incentives can play a role in all these areas, providing a means by which health systems can attract and retain essential and highly sought-after health care professionals. Effective incentive schemes also help build a better motivated, more satisfied and better performing workforce.
This article describes the human resource challenges that managers around the world report and analyses why solutions often fail to be implemented. Despite rising attention to the acute shortage of health care workers, solutions to the human resource (HR) crisis are difficult to achieve, especially in the poorest countries. Although HR strategies have been developed around the issues, the problem is that some old systems of leading and managing human resources for health do not work in today's context. The Leadership Development Program (LDP) is grounded on the belief that good leadership and management can be learned and practiced at all levels. Case studies were chosen to illustrate results from using the LDP at different levels of the health sector. The LDP makes a profound difference in health managers' attitudes towards their work. Rather than feeling defeated by a workplace climate that lacks motivation, hope, and commitment to change, people report that they are mobilized to take action to change the status quo. The lesson is that without this capacity at all levels, global policy and national HR strategies will fail to make a difference.
This article describes the experience of the Family Life Education Programme (FLEP), a reproductive health program that provides community-based health services through 40 clinics in five districts of Uganda, in improving retention and performance by using the Management Sciences for Health (MSH) Human Resource Management Rapid Assessment Tool. A few years ago, the FLEP of Busoga Diocese began to see an increase in staff turnover and a decrease in overall organisational performance. An action plan to improve their human resource management (HRM) system was developed and implemented. By implementing the various recommended changes, FLEP established an improved, responsive HRM system. Increased employee satisfaction led to less staff turnover, better performance, and increased utilisation of health services. These benefits were achieved by cost-effective measures focused on professionalising the organisation's approach to HRM.
In the case of health workers in Mozambique, the brain drain is not the biggest problem, neither are the salaries. There is a pure lack of doctors, with only up to 60 doctors a year being trained at the University for a population of 18 million. The funds from international donors for the National AIDS Plan are not accessible to the Faculty of Medicine to support the basic education of doctors because of restructions placed by donors.
The South African health department has started the training a new category of healthcare worker, but will need more money from treasury if it is to become a sustainable intervention. The first intake of 23 students to be trained as clinical associates, health workers ranked between a nurse and doctor, started at Walter Sisulu University in January this year. It is hoped that the clinical associates will lessen the burden facing critically understaffed hospitals and clinics. The health department has secured funding from the World Health Organisation, the United States Centres for Disease Control, the British government and the European Union to train the 23 students. Another 76 students are expected to be enrolled at the universities of the Witwatersrand, Pretoria and Limpopo as soon as the health department has finalised funding.
The quality and quantity of health care services delivered by the Malawi public health system is severely limited, due to, among other things the shortage of adequate numbers of trained health care workers. In order to suggest policy changes and implement corrective measures, there may be need to describe the perceptions of the legislature on how they perceive as the cause of the problem. Training more health workers, training new but lower cadres of health workers not marketable to the outside world, improving the working conditions and remuneration of health workers are suggested as some of the solutions. Even without the brain drain of health workers to other countries, Malawi's health sector personnel numbers are not adequate to serve the needs of the country. Relying on training more health workers in the numbers normally produced from the prevailing training institutions is unlikely to remove the shortages.
9. Public-Private Mix
Public-private partnership organisations (PPPOs) — which focus on African neglected diseases — have failed to change the imperialist research paradigm or involve African researchers on an equal basis. Every major PPPO is headquartered in Europe or the United States: "Not one 'global' PPPO is led by a person who is a developing-country national, and not one resides within one of the developing countries severely affected by neglected infectious diseases." Senior staff and boards of directors show similar trends. And although disbursements to developing countries have been impressive, "Africans are only able to access resources that (predominantly) non-Africans decide are appropriate." In addition, African states have not created career structures for clinicians and scientists, so there is relatively little capacity to build PPPOs in Africa, a situation which must be changed by African states investing in health-related PPPOs.
The Free State Province in South Africa, with the provincial capital at Bloemfontein, is home to 2.8 million people. But only 13 per cent have private health insurance with most relying on government-operated facilities for their healthcare needs. There are two academic public hospitals in Bloemfontein: Pelonomi and Universitas. In 1997, the government was unable to raise the estimated R825 million needed towards the major renovation of Pelonomi hospital and a partial upgrade of Universitas Hospital. The solution emerged through a public-private partnership between the Philippine national government and the private sector. The PPP was structured for the hospital redevelopment project between three partners.
10. Resource allocation and health financing
Financing Uganda's health care services used to be based on a minimum package which cost more than the financial resources available. Donor aid contributed between 40-50% of these costs. Financial allocations were also biased towards national level hospitals and wages. For Uganda's health care system to become more efficient, reforms in the coordination and allocation of donor aid were essential. The findings show that efficiency gains can be made with a minimal budget increase and shifting of budget priorities. For these shifts to be feasible and sustainable, more donor aid needs to be channelled in a way that enables sector planners and government to implement reforms that affect broader health systems. The sector-wide approach (SWAp) in Uganda increased resources, allowed donor aid to be channelled through budget support arrangements, and gave the Ministry of Health (MOH) greater flexibility to implement reforms. However, the findings also show that increased efficiency cannot necessarily fill the resource gap. Although global financial initiatives can help to address this gap, they also need to strengthen SWAp arrangements, channel more funds through budget support and allow the MOH to adopt the long-term reforms needed for better health system developments.
Today, millions of people in low- and middle-income countries do not have access to basic, good quality health services. The Alma Ata Declaration in 1978 defined primary health care as basic health care built on technically sound and socially adequate approaches, universally accessible and affordable to all individuals. This article explores the challenges facing donors and national governments in providing and financing primary health care for all. Given the high dependency of low income countries on aid, methods of aid delivery are central to the debate on how best to finance PHC. Sector-wide approaches (SWAps) and General Budget Support (GBS) emerged in the late 1980s to 1990s, in response to frustrations with the delivery of aid through 'vertical' projects. Such programmes were problematic because they were defined by donors giving little country ownership. Poor donor coordination lead to fragmentation and duplication of efforts, and governments were unable to respond effectively to different donor requirements.
Given the large size of aggregate remittance flows, they should be expected to have significant macroeconomic effects on the economies that receive them. In addition, remittances have been identified as a potential source of funding for economic development. Thus, two main issues are of interest to policymakers with regard to remittances: how to manage their macroeconomic effects; and how to harness their development potential. This paper directly addresses these two questions by reporting the results of the first global study of the comprehensive macroeconomic effects of remittances on the economies that receive them. The ultimate purpose of this endeavour is to draw summary policy implications for countries that receive significant flows of remittances. In broad terms, the findings of this paper tend to confirm the main benefit cited in the microeconomic literature: remittances improve households’ welfare by lifting families out of poverty and insuring them against income shocks. However, the systematic macroeconomic analysis of remittances developed over important caveats and policy considerations that have largely been overlooked: measurement, fiscal policy, debt sustainability, fiscal discipline, economic growth, Dutch disease effects, governance and incentives and the role of international financial institutions. The main challenge for policymakers, stated in general terms, is to design policies that promote remittances and increase their benefits while mitigating adverse side effects. Getting these policy prescriptions correct early on is imperative. Globalization and the aging of developed economy populations will ensure that demand for migrant workers remains robust for years to come. Hence, the volume of remittances likely will continue to grow, and with it, the challenge of unlocking the maximum societal benefit from these transfers.
The Tanzania National Voucher Scheme (TNVS) uses the public health system and the commercial sector to deliver subsidised insecticide-treated nets (ITNs) to pregnant women. The system began operation in October 2004 and by May 2006 was operating in all districts in the country. Evaluating complex public health interventions which operate at national level requires a multidisciplinary approach, novel methods, and collaboration with implementers to support the timely translation of findings into programme changes. This paper describes this novel approach to delivering ITNs and the design of the monitoring and evaluation (M&E). A comprehensive and multidisciplinary M&E design was developed collaboratively between researchers and the National Malaria Control Programme. Five main domains of investigation were identified: (1) ITN coverage among target groups, (2) provision and use of reproductive and child health services, (3) "leakage" of vouchers, (4) the commercial ITN market, and (5) cost and cost-effectiveness of the scheme. The evaluation plan combined quantitative (household and facility surveys, voucher tracking, retail census and cost analysis) and qualitative (focus groups and in-depth interviews) methods. This plan was defined in collaboration with implementing partners but undertaken independently. Findings were reported regularly to the national malaria control programme and partners, and used to modify the implementation strategy over time. The M&E of the TNVS is a potential model for generating information to guide national and international programmers about options for delivering priority interventions. It is independent, comprehensive, provides timely results, includes information on intermediate processes to allow implementation to be modified, measures leakage as well as coverage, and measures progress over time.
11. Equity and HIV/AIDS
In this position paper, the Coalition raises demands for the improvement of health care in African countries in terms of: improving political commitment and leadership; strengthening civil society to improve absorption of available resources; immediately delivering on the 15% Abuja commitment; scaling up investment in youth empowerment and education to enhance participation of young people in HIV/AIDS; ensuring sustainability of financing and programmes; fast tracking implementation of the global strategy and plan of action on public health, innovation and intellectual property; scaling up HIV prevention, treatment and care; dealing effectively with and invest in programmes for TB/HIV co-infection; addressing the needs of older people and empowering and engaging with PLWHAs.
The study seeks to raise awareness and expand knowledge about the deleterious effect of HIV/AIDS mortality on South Africa's life expectancy, a country with a relatively high HIV/AIDS prevalence rate (19%). Using the multiple and associated single decrement life table techniques, the study estimates the total number of South Africans who would die from HIV/AIDS by the time they reach age 75 from a hypothetical cohort of 100,000 live births, assuming that the mortality conditions of 1996 for South Africa prevailed. The findings indicate that 5.7% of babies will eventually die of AIDS. Furthermore, 7.7% and 11.5% of those aged 60 years, and 75 years and above respectively will die of AIDS. Overwhelming majority of deaths will come from persons within the reproductive and productive age groups. A tremendous gain in life expectancy to the tune of about 26 years would result in the absence of HIV. The elderly persons, who are the grandmothers and grandfathers, are likely to manage family affairs following the death of their adult children. This condition is likely to impoverish the elderly population. Everything should be done to reduce AIDS mortality in order to increase life expectancy in the country.
There has been a great deal of progress over the past few years in AIDS. Despite the still staggering death toll and the wave of new infections, there are now, for instance, 3 million people on antiretroviral therapy, something that would have been unbelievable 10 years ago. This modest progress is in danger though. We've entered the era of the AIDS backlash - those who say AIDS gets too much money, from those who say AIDS programmes are distorting health systems. But the backlash takes more insidious forms. This discussion reports on the progress we've made with HIV/AIDS, the innovations that we've pioneered and the need to stop the backlash.
More than 400,000 HIV-positive South Africans have begun antiretroviral treatment (ART) since the government launched its programme in 2004. But this impressive-sounding figure still only represents one third of the estimated number of people in need of treatment, and that number is expanding by an additional half a million people every year. If South Africa is to achieve its ambitious goals for expanding treatment access, as well as the UN Millennium Development Goal of universal access, the current models for delivering treatment will need an overhaul. Despite the existence of national policies and guidelines for ARV treatment, implementation is strongly driven by what happens at provincial and district level. A comparison of 16 facilities providing treatment in the three provinces revealed wide variations in referral systems and staffing levels, but in all three provinces the researchers found a lack of integration of ARV services with other health services. Patients frequently had to go to other facilities for the treatment of TB, or for other opportunistic infections, or for antenatal care. The study also found that in many districts there were too few doctors and pharmacists providing ARV services, creating service bottlenecks. Systems for monitoring and evaluating patients on ARV treatment were also generally weak, and the use of data to improve services even weaker.
A Durban hospital has cut the transmission of HIV from pregnant mothers to their babies to less than 3% with dual therapy. The study started with all 2 624 pregnant women who attended McCord's antenatal clinic during the 18 months from March 2004 to August 2005. Of these, 338 women tested HIV-positive and 302 delivered at McCord. The study assessed these babies. During their pregnancies 44% of the HIV-positive women received highly active antiretroviral treatment. Of the 297 surviving babies, 290 (98%) received the antiretroviral drug nevirapine after birth and 224 (76%) also received the antiretroviral AZT. In six cases there was no record of the baby receiving any antiretroviral treatment. Six weeks later 239 (81%) of the babies were tested seven of these (2.9%) were HIV positive. The hospital used guidelines developed from international studies for its programme. The researchers said this showed that, despite resource constraints, a state-aided hospital could achieve results which compared favourably to those in developed countries.
East and southern Africa are the two regions in the world which are the most highly affected by HIV and AIDS. A significant number of people with HIV are educators, ranging from primary school teachers to head teachers and university lecturers. In response, UNESCO together with the three partners convened a consultation with HIV-positive teachers and other key stakeholders from Ministries of Education and teachers’ unions from Kenya, Namibia, United Republic of Tanzania, Uganda, Zambia and Zimbabwe. This report presents a summary of the key points, outcomes and recommendations emerging from the consultation which aimed to share experiences and articulate common, key elements of comprehensive responses for HIV-positive teachers. In order to provide a comprehensive response for HIV-positive teachers, the report argues that there needs to be support for HIV-positive teachers to continue teaching in a supportive environment free of stigma and discrimination. For this to be in place, a number of actions are recommended as necessary, including to: identify and address the varying needs of HIV-positive teachers; tackle stigma and discrimination; ensure access to prevention programmes, treatment, care and support; and build links between teacher’s unions and networks of HIV-positive teachers.
Mozambique had 1.3 million people estimated to be living with HIV by end 2003. The epidemic poses significant development challenges to this low-income country. The Government of Mozambique formed a National AIDS Council (NAC) in 2000, and is currently operating its National Strategic Plan to Combat HIV/AIDS for 2005-2009.
This World Health Organisation/UNAIDS/UNICEF report documents appreciable global progress in the effort to deliver lifesaving antiretroviral treatment (ARVs) to people living with HIV/AIDS in developing countries; however, it also underscores the crucial need to maintain a focus on scaling up and providing lifesaving antiretroviral treatment in programs like PEPFAR (the President’s Emergency Plan for AIDS Relief) notes AIDS Healthcare Foundation (AHF). The report claimed that three million people were on treatment in 2007 (a goal that World Health Organization officials had initially hoped to reach in 2005 in its ambitious ‘3x5’ treatment plan), but it also revealed a more ominous trend that AHF and other advocates believe calls for a renewed and stepped up commitment to delivering care and antiretroviral treatment—more than 9.7 million people with HIV/AIDS around the world are in critical need of antiretroviral treatment (those who would otherwise die within two years) than at the end of 2006; 2.6 million more are in need today than one year ago.
12. Governance and participation in health
Participation is important in developing countries as a means of improving the performance and accountability of bureaucracies and improving social justice. There are two basic criteria for participation: it should be broadly representative of the population and should involve meaningful discourse that affects public decision-making. Reviews of participation in Poverty Reduction Strategy Paper (PRSP) processes show that these criteria have not been met in most cases. However citizen involvement in budgeting has been more successful. Citizen participation made local service delivery more efficient and effective in the country cases reviewed. In most of the case studies, NGOs analysed the budget and mobilised citizens. These NGOs seek to represent the poor and disseminate their views to the government. They do not offer direct citizen involvement, but without their involvement participation would be reduced. Budget participation can influence governments even where they have not embraced direct involvement of citizens in decision-making. This depends on NGOs communicating analyses of spending choices, public service effectiveness, and budget execution to the public, media, and elected officials. A key policy implication for donors is therefore targeted support to civil society. However, donors and NGOs often overlook the importance of government administrations in implementing participation.
Civil society members and advocates for health care from all over the world met to discuss the International Health Partnership and Related Initiatives (IHP+) 'Scaling Up for Better Health Plan', aimed at strengthening primary health care to achieve the health-related MDGs for developing countries around the world, including Africa. In order to deliver on its stated goals, they believe the IHP+ must commit to a minimum set of guidelines. These civil society member and advocates stand united on three key principles that they consider non-negotiable: 1) Comprehensive primary health care must be provided for all. 2) Governments must pay their fair share. 3) The people’s voices must be heard.
It is now more than 3 weeks since widespread xenophobic terror against foreign nationals has erupted in provinces across South Africa. To date, over 20,000 people in the Western Cape have been displaced, some are staying in community halls and local shelters, but many have been taken to refugee camps, some against their will. Across our country more than 50 000 people were displaced. The displaced peoples' calls for the UN including (UNHCR) intervention have only grown louder, and were the main demand at a rally and press conference held by them in Cape Town. The groups are concerned that the UN seems to publicly take a position that they cannot assist unless and until the South African government requests their intervention and are unsure when that is likely to happen. TAC observes that the humanitarian crisis in South Africa continues to deepen.
TAC presents demands to the Cape Town City Council about the treatment of foreigners after the xenophobic attacks in the city.
13. Monitoring equity and research policy
Many countries in the African region do not have functional national health research systems (NHRS) that generate, disseminate, uses, and archives health-related knowledge/ideas in published form (hard, electronic or audio forms). In such countries, death of each modern or traditional health practitioner constitutes a permanent loss of a library of knowledge, ideas, innovations and inventions. The WHO African Advisory Committee on Health Research and Development (AACHRD) has attributed the fragility of NHRS in the Region to poor environment for research, inadequate manpower, inadequate infrastructures and facilities, inaccessibility to modern technology, and lack of funds. The weak and uncoordinated NHRS partly explain the poor overall performance of majority of national health systems in the Region. Continued fragility of NHRS can be attributed to lack of implementation of the WHO Regional Committee for Africa and the World Health Assembly resolutions on health research. This paper urges African countries, to fully implement the contents of those resolutions, for substantive health research outputs to share with the rest of the world at the next Ministerial Summit on Research for Health, which will take place in the African Region in 2008.
Public health programmes operate without uniform, empirical measures, a fact often forgotten amidst recent enthusiasm for modelling public health on the private sector, where the dollar dictates strategic and operational priorities. As a result, it is surprisingly difficult to determine whether or not public health interventions work and whether their benefits are equitably distributed. Certainly, the medical bases for most interventions are sound. There can be little doubt that standardised treatment regimens cure tuberculosis or that oral rehydration resuscitates children with diarrhoeal illnesses. History, however, shows that medical science is neither necessary nor sufficient for effectiveness. Public health interventions succeeded in controlling problems from scurvy to smallpox to cholera to puerperal fever decades before medical science identified causative agents or specific therapies. Proof that medical interventions work is generated in carefully controlled, highly resourced environments. The validity of this evidence must be re-evaluated after translation into policy, especially in the poor, chaotic conditions of the developing world. The same interventions are seldom evaluated in low-resource comparison groups and, indeed, the same measures of effectiveness – like CD4 count or ejection fraction – would be impractical. Such conditions pose enormous challenges to research and implementation alike. Resources are limited, data are scarce, bias is abundant and few validated techniques exist for analysis on a scale larger than the individual case study.
The annual meetings of the Global Forum are premier international events for stakeholders in health research for development. This Forum 11 report provides an overview and synthesis of the key issues discussed and conclusions reached. These include: the need for additional research; better systems of organizing and funding research, for ensuring participation in the process by all the stakeholders and for facilitating research to ensure impact on the health of those in need. Other central themes include: expanding the use of evidence in policy- and decision-making; equity and human rights (access and inclusion); encouraging innovation in research; research priority setting; research capacity strengthening; possibilities with inter-sectoral collaboration; advocacy for more research and resources; and communication of research results.
In preparation for the forthcoming Ministerial Forum on Health Research, to be held in Bamako, Mali in November 2008, more than 40 researchers from 28 countries, both in the South and the North, who have a particular interest in health policy and systems research (HPSR) and the application of evidence to health policy, gathered in Nyon, Switzerland on 25-27th May to: critically assess developments in HPSR in low and middle income countries and its application to policy since the Mexico Summit, 2004; highlight current gaps, priorities and challenges in the HPSR field that need to be addressed; and discuss and agree how best to move forward the HPSR field. Meeting participants reviewed evidence about the evolution of the HPSR field and debated emerging needs, with a view to informing discussions at Bamako, and further action by the institutions sponsoring and participating in the meeting, as well as by other key stakeholders including national governments, researchers, research and development funders.
Inadequate reporting is problematic for several reasons. If authors do not provide sufficient details concerning the conduct of their study, readers are left with an incomplete picture of what was done. As such, they are not able to judge the merits of the results and interpret them. The EQUATOR Network is a new initiative aimed at improving the clarity and transparency of reporting health research.
Perceptions in health research are a product of the circumstances within the society, where the research activities are situated. In East Africa there has been a change in conceptualisation over a period of time from an elitist de-linked status to the present, which has evolved to embrace the local community. In this paper, researchers trace the changes and highlight some occurrences that exerted the greatest influence in shaping the notions that currently dominate in research. They conclude that the paradigm shift is a positive development and that the present conception is suitable for heath research at this point in time.
14. Useful Resources
Participatory budgeting in Africa is part of an effort to build the capacity of local government officials and their partners for greater accountability and good governance. This toolkit is aimed at helping local governments and other stakeholders to prepare for, design, initiate and manage a participatory budgeting process, by training key actors who initiate the budgeting processes. This is the second of two volumes that provide users with information, tools, methodologies, case studies and tips on how participatory budgeting can be introduced and sustained. These resources have been collected from local governments where participatory budgeting is already being practised.
The Pretoria University Law Press (PULP) is based at the Faculty of Law, University of Pretoria, South Africa. PULP endeavours to publish and make available innovative, high-quality scholarly texts on law in Africa. PULP also publishes a series of collections of legal documents related to public law in Africa, as well as text books from African countries other than South Africa. On their website, they have interesting information on human rights and HIV and give case studies from southern African countries.
15. Jobs and Announcements
In order to ensure a broader participation of social movements and organisations in the building of objectives for the World Social Forum 2009, the Belem's Organising Committee and the IC Methodology Commission has agreed to extend the consultation period to 25 June 2008. Civil society organisations and social movements are invited to visit the website and make their comments about the nine goals established for the 2007 WSF in Nairobi, as well as make suggestions of new objectives to the World Social Forum 2009.
The NGO Delegation to the UNAIDS PCB has vacancies for two-year terms, beginning 1 January 2009 and ending 31 December 2010, for the position of Africa Alternate Delegate. This represents a unique opportunity for committed activists and HIV/AIDS advocates to make a difference to HIV/AIDS policy implementation in their regions. The position of NGO Delegates to the UNAIDS PCB is important to the effective inclusion of community voices in the key global forum for HIV/AIDS policy. NGO Delegates represent the perspectives of civil society, including people living with HIV, within UNAIDS policies and programming. The closing date is Tuesday, 31 August 2008.
The mission of the International Women's Programme (IWP) of the Open Society Institute is to use grant-making and programmatic efforts to promote and protect the rights of women and girls in priority areas around the globe where the principles of good governance and respect for the rule of law are absent or destroyed because of conflict. IWP seeks to promote the advancement of women’s rights and gender equality in law and practice, and the empowerment of women to ensure participation in the democratic processes. Organisations can apply for one- to three-year grants, ranging from US$25,000 to US$200,000. The deadline for proposal submissions is 7 July 2008.
The aim of this new initiative of the WHO World Alliance for Patient Safety is to stimulate research in patient safety worldwide by providing funding for small research projects. It is envisaged that the initiative will also contribute to building local research capacity as well as help raise awareness about patient safety issues. Proposals to identify, develop and/or test local interventions for improving patient safety, as well as studies on the cost-effectiveness of risk-reducing strategies, are invited. Funding will be available to support up to 30 projects to begin in 2009. Grants of between US$10,000 and US$25,000 per project will be awarded on a competitive basis. The grants will target well-defined research projects that can be completed within 12–18 months. Research in all methodological and clinical disciplines that address patient safety is encouraged. The proposed studies may be conducted in any health-care setting. Research to be conducted in developing countries and countries with economies in transition is particularly encouraged. The deadline for submissions is 30 September 2008.
This two-year (2008-2010) programme offers highly qualified researchers working on issues of globalisation from a feminist perspective, from developing countries in Africa, the Middle East, Asia, Latin America, the Caribbean and the South Pacific, the opportunity to spend a research term in Ottawa based at one of the two universities. The Visiting Scholar in Feminist Perspectives on Globalisation will contribute to gender and development research at both universities and provide a unique opportunity for collaboration between feminist scholars in Canada and the developing world and between North and South. The Pauline Jewett Institute of Women’s and Gender Studies and the Institute of Women’s Studies will alternate in welcoming one visiting scholar per year. However, both Institutes look forward to the opportunity of engaging with the Visiting Scholar. Applications are invited for the 2008-2009 Visiting Scholar in Feminist Perspectives on Globalisation to be based at the Pauline Jewett Institute of Women’s and Gender Studies at Carleton University. (In 2009-2010, the Visiting Scholar will be based at the University of Ottawa Institute of Women’s Studies.)
The Global Fund Board just announced the launch of round 9 which will open on 1 October 2008. This is an additional round in order to accelerate progress towards Universal Access and will be followed by the next in March 2009. The opening date is 1st October 2008, the closing date (submission deadline) is not finalised yet and the round 9 grants are expected to be approved by May 2009. Round 9 will use the same proposal form and guidelines that were issued for round 8 - without changes. Round 9 is for new proposals, and it is also an opportunity for countries to resubmit proposals that were rejected in round 8, six months earlier than usual. CCMs will receive Technical Review Panel (TRP) reviews for round 8 one month earlier than usual, so that they have them in time for preparing the round 9 application if necessary.
IPHU and the People’s Health Movement in association with the School of Public Health of Rio Grande do Sul are pleased to announced 'The Struggle for Health', a two week short course for health activists, scheduled for 8-19 September, 2008. The Porto Alegre IPHU will address all of the 'standard' objectives of other IPHU courses. Participants should come prepared: to describe in some detail an activist project or campaign or movement that they have been directly involved in; to describe in sufficient detail for the strategies, theories and skills of practice to be evident; and to provide an overall assessment of the health challenges in their country and the status and prospects for PHM. Students should also come prepared to comment on the implications for their own countries of the material covered in the different topics. For example: what is the extent of brain drain and what is being done about it; what is the role of the WB and IMF in health sector reform; what are the implications of the WTO (eg GATS); what is the role of the GFATM in own country; and access to medicines? The courses involve: lectures, small group discussions, debates, workshops and field trips and follow up study. Resource materials will take the form of hard copy readings, lecture notes and websites. Applications should be submitted on the internet.
The School of Public Health is one of the research partners in a four-year EU-funded research project (INCO-DEV) being implemented in three Southern African countries (Angola, Mozambique and South Africa). The study aims to understand how the rise of Global Health Initiatives (e.g. Global Fund to Fight AIDS, TB and Malaria, PEPFAR etc) has impacted the architecture of development partnerships and country-level health systems’ functions. They are calling for applications from South African junior researchers who will be part of a research team that has been put together to implement the GHIs project.
The SADC Secretariat is inviting tenders to review the SADC HIV and AIDS Strategic Framework (2003-2007) and the instruments for its operationalisation. The deadline for the bid is 7th July 2008 at 16.00hrs. Tenders should be admitted in two sealed separate envelopes clearly labeled Technical Proposal and Financial Proposal and both with the inscription: REVIEW OF THE SADC HIV AND AIDS STRATEGIC FRAMEWORK. The proposals should be addressed to: The Secretary, SADC Internal Tender Evaluation Committee (SITEC), SADC Secretariat, KHAMA CRESECENT, PRIVATE BAG 0095, BOTSWANA. Please note that faxed or emailed proposals will not be considered. The terms of reference are available at the link above.
The Think Tank Initiative invites applications from independent African organisations that are committed to using research to inform and influence social and economic policy. The Initiative will provide multi-year funding to promising think tanks, and will work with successful applicants to improve their organizational performance. The Think Tank Initiative is a new, multi-donor program dedicated to strengthening independent policy research institutions – or “think tanks” – in developing countries, enabling them to better provide sound research that both informs and influences policy. The Initiative will focus its activities in East and West Africa, South Asia and Latin America. The deadline for submissions is 19 August 2008.
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