In the next six months countries in the east and southern African region will be negotiating the agreements on services in the European Union (EU) – East and Southern Africa (ESA) Economic Partnership Agreements. These services negotiations are already halfway through and are expected to be complete by the end of 2008. The negotiations currently cover mainly financial and telecommunications services, and say little about protecting social services. Yet many countries in the region are facing pressures to privatise health services, even though the growth of a private sector in health services withdraws resource and staff to service a wealthier minority at the cost of universal access to health care services for the majority.
Protecting the health of the populations in the sixteen eastern and southern Africa in the region is a development priority. Twelve of them are least developed countries (LDCs) with the lowest human development indicators in the world. Almost all these countries experience negative economic growth and falling disposable incomes, one in six children dies before their fifth birthday and more than half the population is still living on less than US$1 a day. The EU on the other hand, with whom the agreements are being negotiated, consists mainly of developed economies, five of which are among the ten largest economies in the world and most of their people enjoy high standards of living. These negotiations are clearly taking place between unequal partners.
Countries in ESA experienced a wave of liberalisation of health services under the Structural Adjustment Programmes (SAPs), with a fall in funding of and access to services by the poorest communities. Further liberalisation is opening up services to commercial players whose aim is to generate profit. Trade in health services is argued to increase access to health care in remote and under-serviced areas; to generate foreign exchange; to provide new employment, give access to new technologies; and to reap economic gains from remittances of health workers who migrate. However, these benefits are often only obtained in the private for profit health care sector, promoting internal migration from the public health sector to private health care, with unaffordable costs of care for poor and vulnerable members of society, whose needs must be assured by governments.
Governments in the region have recognised the need for public sector led services for access to health care in poor populations, even while some have permitted the growth of private services. Universal access to basic health services is a stated development goal in many ESA countries. Health is a human right enshrined in many national constitutions and various signed and ratified international legal instruments.
Yet there is little protection of the right to health or to health care in the interim EPA agreements initialled in 2007. When these were concluded, despite significant opposition from the region, their sections on development cooperation should have provided for protection of public health, but no such protection was included.
The SADC-EU EPA Article 3 (2) provided that ‘The Parties understand this objective to apply in the case of the present Economic Partnership Agreement as a commitment that:(a)the application of this Agreement shall fully take into account the human, cultural, economic, social, health and environmental best interests of their respective population and of future generations (my emphasis)’ This gives some basis for ensuring that the rest of the EPA negotiations protect health rights, and it will be important to keenly follow the SADC EPA negotiations to hold negotiators to the commitment to protect their people’s best interests in health. Despite lobbying from civil society, the ESA-EU EPA on the other hand does not contain any mention of protecting health except reaffirming the parties’ commitments to the realisation of the millennium development goals in the preamble to the agreement.
Both interim EPAs however included a clause opening the way for further negotiations in areas relevant to health, such as services, intellectual property rights, and investment. These further negotiations appear likely to motivate liberalisation of services. This is promoted in the guidelines set out in the General Agreement on Trade in Services (GATS) of the World Trade Organisation (WTO) and the EPA is modelled along GATS. It is likely to cover similar areas, including health and health related services, migration of health professionals, and health care financing.
How can ESA countries protect their health services in the negotiations?
Firstly, as a minimum, it is important that the EPA negotiations do not go beyond the framework agreed at the WTO in the GATS and do not include GATS-plus obligations. Negotiators should live up to the commitment of the 4th Ordinary Session of the AU Conference of Ministers of Trade in April 2006: ‘We shall not make services commitments in the EPAs that go beyond our WTO commitments and we urge our EU partners not to push our countries to do so.’
However countries can go further. Under the terms of the interim EPAs, countries are free to exclude a wide range of sensitive goods and sectors from liberalisation. Our governments should take advantage of this flexibility to exclude health and related social services from liberalisation. For governments like Zambia and Malawi whose health service sectors are already open under GATS, they should not further entrench liberalisation under EPAs.
Negotiators must protect government policy space to remain key providers of health services in the EPA negotiations. Negotiators need to ensure that governments have full authority to regulate and control private for profit provision and financing of health services. Governments should also do formal health impact assessments in any health-related sector where liberalisation is being proposed, whether under GATS or the EPA. Commitments should be explicitly made in the EPAs on ethical recruitment and treatment of health workers and on EU investment in public budgets to produce and retain health workers in source countries.
ESA negotiators cannot treat health and health care services as a market matter, divorced from social issues. What is discussed in these negotiations are not just a matter of people’s survival, but also affect the cohesiveness and solidarity of societies and the support ESA countries are able to give to vulnerable communities. The negotiations on health services are thus a matter of public interest, and civil society should be involved. Public consultation on negotiations will surely strengthen the hand of negotiators by ensuring there is a strong public mandate to take firm positions on these vital health issues. Civil society should track the services negotiations, parliaments should ask questions about them, and we should continue to lobby for an EPA that respects the rights of the African people, especially the right to health. This means continuing to demand that ESA governments and the EU member states respect their obligations to international human rights instruments as they negotiate EPAs and that the people’s welfare takes priority.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue or the full please visit SEATINI (www.seatini.org) or EQUINET www.equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
In Kenya, internal migration of workers, from rural/poor areas to urban/rich areas, is just as serious a problem as international migration. Shortages in the health workforce are aggravated by the unequal distribution of health workers as a result of economic, social, professional and security factors. This report is of a literature review and field research on strategies for the retention of health workers in Kenya. It examines trends in health worker recruitment and retention; existing policies, strategies and interventions to retain health workers; and assesses their implementation and the factors affecting this. The study data suggests that better organised facilities, often in higher-income areas, are more successful in providing incentives. Yet it is at the lower levels of the health system (in rural and poorer areas) where incentives are more urgently needed to counteract the strong push factors that force workers out of these areas. Recommendations are proposed for measures to retain health workers in rural areas, in lower-income districts and at lower levels of the health system to ensure that all areas reach minimum standards with regard to numbers of personnel per population. Such incentives are not only financial. A number of non-financial incentives are highly valued: improved working conditions; training and supervision; and good living conditions, communications, health care and educational opportunities for themselves and their families.
This document compiles twenty one editorials of the newsletter of the Regional Network for Equity in Health in East and southern Africa from January 2007 to April 2008 translated into Portuguese. The issues covered range from debates and policy positions on financing for health to the public health impacts of criminalising HIV transmission. The editorial content reflects a range of authors from academic, professional and civil society groups and not the views of the EQUINET steering committee.
The Third EQUINET Regional Conference on Equity in Health in east and southern Africa will be held at Speke Conference Centre, Munyonyo, Kampala, Uganda September 23-25, 2009. People are welcome from government, non-state organisations, academic and research institutions, civil society, parliaments, regional and international organisations and other institutions promoting and working on equity in health in east and southern Africa! The conference theme is 'Reclaiming the Resources for Health: Building Universal People Centred Health Systems in East and Southern Africa' and it will highlight opportunities for improving health equity in east and southern Africa.
3. Equity in Health
Sub-Saharan Africa is not on track to achieving a single Millennium Development Goal, and is the only region in the world where malnutrition, an outcome of food insecurity, is not declining. This paper presents the Red Cross Red Crescent five-year strategic framework on long-term food security for Africa. Guided by the 2000 Ouagadougou Declaration and the Algiers Plan of Action 2004, it aims to reduce food insecurity in communities vulnerable to disasters and/or affected by HIV/AIDS. The paper notes that interventions will be evidence-based and will be driven by good practice developed both internally and externally. Programmes will be developed with the full consultation and participation of vulnerable communities in order to ensure that programmes build on the existing assets, capabilities and priorities of the communities and are owned by them.
Malnutrition affects about 30% of children in Africa, caused by low birth weight and post-natal growth faltering. Child malnutrition is a persistent problem. The long term trend shows only slow improvement, and malnutrition rates worsen during droughts, economic crises, conflicts and displacement, and HIV. Without greater attention to nutrition, increased child mortality, morbidity and impaired intellectual development are inevitable. Policies must tackle intermittent crises through emergency programmes and support sustained community-based programmes. Nutrition should be reinstated as a priority programme area alongside HIV, tuberculosis and malaria.
4. Values, Policies and Rights
Prior to 2007, forced sex with male children in South Africa did not count as rape but as "indecent assault", a much less serious offence. This study sought to document prevalence of male sexual violence among school-going youth. Teams visited 5162 classes in 1191 schools, in October and November 2002. A total of 269,705 learners aged 10-19 years in grades 6-11. Of these, 126,696 were male. Schoolchildren answered questions about exposure in the last year to insults, beating, unwanted touching and forced sex. They indicated the sex of the perpetrator, and whether this was a family member, a fellow schoolchild, a teacher or another adult. Respondents also gave the age when they first suffered forced sex and when they first had consensual sex. Some 9% (weighted value based on 13915/127097) of male respondents aged 11-19 years reported forced sex in the last year. Of those aged 18 years at the time of the survey, 44% (weighted value of 5385/11450) said they had been forced to have sex in their lives and 50% reported consensual sex. Perpetrators were most frequently an adult not from their own family, followed closely in frequency by other schoolchildren. Some 32% said the perpetrator was male, 41% said she was female and 27% said they had been forced to have sex by both male and female perpetrators. Male abuse of schoolboys was more common in rural areas while female perpetration was more an urban phenomenon. This study uncovers endemic sexual abuse of male children that was suspected but hitherto only poorly documented. Legal recognition of the criminality of rape of male children is a first step. The next steps include serious investment in supporting male victims of abuse, and in prevention of all childhood sexual abuse.
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 17 May 2008 following presentation of the Health Strategy last year 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.
Many organisations work to eliminate undernutrition in children and pregnant and lactating women in developing countries. These organisations - international organisations, donors, academia, civil society and private sector - are loosely linked as an international nutrition system. However, this system is fragmented and dysfunctional. Individual organisations and the system as a whole must examine their strategies, resources and motivations. Organisations must significantly improve their links with national level processes, so that country level priorities are better reflected in international guidance, donor funding, research and training.
5. Health equity in economic and trade policies
The year 2008 is halfway to the deadline for reaching the Millennium Development Goals. Despite some progress, this article argues that they will not be achieved if current trends continue. Starting with the G8 meeting in Japan, rich countries must use a series of high-profile summits in 2008 to make sure the MDGs are met, and tackle both climate change and the current food crisis. Oxfam proposes an agenda into the G8 this year that includes action on specific areas: stop burning food and start supporting poor farmers; mend broken aid promises; support health, education, water and sanitation for all; and put women and girls first. The report points to a similar situation regarding climate change, where it argues that a lot of the money pledged to help poor communities to cope with the effects of changing weather patterns is simply being taken from existing aid budgets or being made into loans.
Concerns ran high in some developing countries last week that their voices have been largely absent from a draft set of standards for heightened intellectual property enforcement advancing rapidly at the World Customs Organization. With the draft standards sent early - and, some say, without mandate - to decision-making bodies at the WCO, the organisation looks poised to become the next major platform for debate on global enforcement of intellectual property, as members discuss the possibility of incorporating IP protection into customs law.
In the WTO negotiations, there is a push towards the liberalisation of new services sectors by countries. However it is felt that basic services should be excluded, such as education, health, water, energy and telecommunications from the text of the WTO’s General Agreement on Trade in Services. These services are human rights that cannot be objects of private commercial relations and of liberalisation rules that lead to privatisation. The deregulation and privatisation of financial services, among others, are the cause of the current global financial crisis. Further liberalisation of services will not bring about more development, but greater probabilities for a crisis and speculation on vital matters such as food. The intellectual property regime established by the WTO has most of all benefited transnational corporations that monopolise patents, thus making medicines and other vital products more expensive, promoting the privatisation and commercialisation of life itself, as evidenced by the various patents on plants, animals and even human genes.
At its eighth executive board meeting in Geneva on 2 and 3 July, market-oriented drug purchasing mechanism UNITAID agreed to the principle of establishing a patent pool - that is, a collection of intellectual property assets with the consent of their rights holders, for easier licensing to third party manufacture or researchers. This “landmark” decision for drug financing in poor and underserved areas agrees on the usefulness of sharing intellectual property rights to lower costs and increase quality of needed medicines.
6. Poverty and health
The high world food prices currently being experienced provide a chilling reminder of the vulnerability of large parts of sub-Saharan Africa and South Asia to hunger and undernutrition. Many children in these regions are vulnerable to poor growth, poor development and death. Topics covered in this paper include: child undernutrition in Africa; nutrition for mothers and children; the cost of hunger; why undernutrition is not a higher priority for donors; and public-private sector partnerships in responding to undernutrition.
Article 25.2 of the Universal Declaration of Human Rights establishes that motherhood and childhood are entitled to special care and assistance. Yet maternal and child undernutrition are still highly prevalent in most developing countries. This article outlines the role of the World Food Programme (WFP) in tackling undernutrition. It concludes that WFP programmes can contribute to breaking traditional gender barriers, such as the view that caring for children is the sole responsibility of women. It can bring communities together around a common goal of improving maternal and child nutrition for the benefit of society. In communities where the WFP also operates School Feeding programmes, there are opportunities to link school feeding to wider nutrition issues and advocate the importance of nutrition throughout a person's lifecycle.
Widespread chronic poverty occurs in a world that has the knowledge and resources to eradicate it. This report argues that tackling chronic poverty is the global priority for our generation. There are robust ethical grounds for arguing that chronically poor people merit the greatest international, national and personal attention and effort. Tackling chronic poverty is vital if our world is to achieve an acceptable level of justice and fairness. Currently, development research is mainly assessed in terms of its contribution to meeting the Millennium Development Goals, in particular MDG1: to halve absolute poverty by 2015. However, achieving the first MDG would still leave some 800 million people living in absolute poverty and deprivation – many of whom will be chronically poor. Their lives are extremely difficult and, being marginalised, their story is rarely told. This report tries to tell parts of their story. It does so through the lives of seven chronically poor people:Maymana, Mofizul, Bakyt, Vuyiswa, Txab, Moses and Angel. Chronic poverty is a varied and complex phenomenon, but at its root is powerlessness. Poor people expend enormous energy in trying to do better for themselves and for their children. But with few assets, little education, and chronic ill health, their struggle is often futile.
The mandate of most international donors is to reduce poverty, suffering and inequity. Addressing child undernutrition falls within this. However, current donor investment to directly address undernutrition is estimated to be well under half of the resources required. Encouragingly, some new initiatives to increase investment and improve coordination are already underway. Several international agencies are working together to develop a Ten Year Strategy to reduce vitamin and mineral deficiencies. These include the United Nations Children's Fund (UNICEF), the Academy for Educational Development and the Global Alliance for Improved Nutrition (GAIN). They have completed a technical situation analysis (published in the Food and Nutrition Bulletin) and formed working groups to better coordinate their actions, including monitoring and evaluation activities.
7. Equitable health services
A lack of laboratory facilities, transport and skilled medical workers is reported to be hampering efforts to tackle an outbreak of visceral leishmaniasis, a parasitic disease also known as kala azar or black fever, in northern Kenya’s Isiolo and Wajir districts, officials said. According to public health officials in the district prevention and management of the disease is limited by the availability of trained personnel.
KwaZulu-Natal seems to be winning the battle against malaria in the province, with only about 1,000 cases reported in the province in the past malarial season. According to Prof. Maureen Coetzee, an entomologist from the University of the Witwatersrand, in a paper presented to the International Congress of Entomology in Durban, the situation in the province and the country is favourable because of reduced rainfall and the changes made to malaria control programmes, with use of two insecticides to control mosquitoes and a change to the drug for treatment of the parasite. Similar control programmes have also been introduced in Mozambique. The use of fungi to kill mosquitoes is being tested and research at Wits University showed that mosquitoes exposed to
fungi died within 12 to 14 days after exposure.
People in low-resource countries who are ill with multidrug-resistant TB (MDR-TB) will get a faster diagnosis and a new treatment regime, thanks to two new initiatives unveiled by the World Health Orgqnisation, the Stop TB Partnership, UNITAID and the Foundation for Innovative New Diagnostics (FIND). On diagnosis, the method gives results in two days rather than the standard two to three months. At present it is estimated that only 2% of MDR-TB cases worldwide are being diagnosed and treated appropriately, mainly because of inadequate laboratory services. The initiatives should increase the proportion diagnosed and treated at least seven-fold over the next four years, to 15% or more.
Scaling up the implementation of new health care interventions can be challenging and demand intensive training or retraining of health workers. This paper reports on the results of testing the effectiveness of two different kinds of face-to-face facilitation methods used in conjunction with a well-designed educational package in the scaling up of mother care. A previous trial illustrated that the implementation of a new health care intervention could be scaled up by using a carefully designed educational package, combined with face-to-face facilitation by respected resource persons. This study demonstrated that the site of facilitation, either on site or at a centre of excellence, does not affect implementation abilities at the hospital service level. The choice of outreach strategy should be guided by local circumstances, cost and the availability of skilled facilitators.
8. Human Resources
Since 1994, higher education policy has been committed to equity of access for all, irrespective of race and gender. This study investigated progress towards these goals in the education of medical doctors, with an emphasis on gender. Databases from the Department of Education (DoE), Health Professions Council of South Africa (HPCSA) and University of Cape Town (UCT) Faculty of Health Sciences were used to explore undergraduate (MB ChB) trends at all eight medical schools and postgraduate (MMed) trends at UCT. Nationally women have outnumbered men in MBChB enrolments since 2000, figures ranging between 52% and 63% at seven of the eight medical schools in 2005. However,the rate of change in the medical profession lags behind and it will take more than two decades for female doctors to outnumber male doctors. A study of UCT postgraduate enrolments shows that females had increased to 42% of MMed enrolments in 2005. However, female postgraduate students were concentrated in disciplines such as paediatrics and psychiatry and comprised no more than 11% of enrolments in the surgical disciplines between 1999 and 2005. The study provides a basic quantitative overview of the changing profile of medical enrolments and raises questions about the career choices of women after they graduate and the social factors influencing these choices.
This article is the third in the Human Resources for Health journal's feature on the theme of leadership and management in public health leadership. It presents a successful application in Mozambique of a leadership development programme created by MSH, in which managers from 40 countries have learned to work in teams to identify their priority challenges and act to implement effective responses. From 2003 to 2004, 11 health units in Nampula Province participated in a leadership and management development programme called the Challenges Programme. The programme used several strategies that contributed to successful outcomes. It integrated leadership strengthening into the day-to-day challenges that staff were facing in the health units. Participatory teams were also created. After the programme, people no longer waited passively to be trained but instead proactively requested training in needed areas. Ministry of Health workers in Nampula reported that the programme's approach to improving management and leadership capacity at all levels promoted the efficient use of resources and empowered staff to make a difference.
The Global Health Workforce Alliance (GHWA) strongly welcomes G8 leaders’ commitment, in Hokkaido, Japan, to actively address the critical shortages of health workers across the world. GHWA applauds Japan and the other G8 nations for recognizing that a competent, supported health workforce is fundamental to developing robust health systems and to reaching health and development goals. GHWA also welcomes the G8’s noting of the importance of the Kampala Declaration and Agenda for Global Action to help guide the response to the health workforce crisis. While encouraged by the increased commitment shown by the G8, GHWA urges the leaders follow up with increased and new investment to ensure promises on the health workforce are turned into reality.
In common with other developing countries, South Africa's public health system is characterised by human resource shortfalls. These are likely to be exacerbated by the escalating demand for HIV care and a large-scale antiretroviral therapy (ART) programme. Focusing on professional nurses, the main front-line providers of primary health care in South Africa, this study examines patterns of planning, recruitment, training and task allocation associated with an expanding ART programme in the districts of one province, the Free State. The researchers found that introduction of the ART programme has revealed both strengths and weaknesses of human resource development in one province of South Africa. Without concerted efforts to increase the supply of key health professionals, accompanied by changes in the deployment of health workers, the core goals of the ART programme - i.e. providing universal access to ART and strengthening the health system - will not be achieved.
Health-care provision in KwaZulu-Natal is reported to be approaching crisis with understaffing. Chronic under-funding continues of the provincial health department is reported to have led to critical posts being frozen, with existing staff, especially nurses, carrying heavier loads. This was reported by senior department officials during a health portfolio committee meeting in the KwaZulu-Natal legislature.
The shortage of health staff in developing countries has led to renewed interest in community-based health care workers. However, poor populations are increasingly accessing health services from a wide variety of providers operating as private or semi-private agents in unregulated markets. Community health workers with little formal training do have a future. However, they will need to adapt to an environment where they must compete with other providers and prove their competence. They need to establish legitimacy and trust, and this is more likely in larger community development programmes with regular monitoring. They also need a livelihood that can be sustained.
Imbalances in quantity and quality of human resources for health (HRH) are increasingly recognised as perhaps the most critical impediment to achieving health outcome objectives in most African countries. However, reliable data on the HRH situation is not readily available. Some countries have hesitated to act in the absence of such data; other countries have not acted even when data are available while others have moved ahead in spite of the lack of reliable information. This paper addresses the issue of data use for HRH policy-making. It will provide valuable information to the body of literature available to policy-makers and their development partners as they grapple with the development and implementation of workable HRH policies.
9. Public-Private Mix
What role can non-state providers play in scaling up healthcare delivery to meet the Millennium Development Goals? A policy briefing paper for the UK Department for International Development addresses this question using case studies in Bangladesh, India, Malawi, Nigeria, Pakistan and South Africa. Non-state providers (NSPs) of healthcare, whether philanthropic or commercial, exist outside the public sector. Research by the London School of Hygiene and Tropical Medicine found evidence that NSPs provide the majority of primary contacts with the health system in all six countries, except possibly South Africa. This is true for poor and rich alike. Poorer households are likely to spend a higher proportion of their income on private sector care than the rich, while the rich tend to access higher quality services. For successful and sustainable collaboration between governments and NSPs, the author recommends that donors should: encourage trust between state and non-state sectors; enable smaller providers, which may have greatest coverage of the poor, to come together to interact with governments and donors; and invest resources and expertise to develop human, transport and technical monitoring capacity; support policy formulation, management and research.
Medical aid coverage is lowest among black South Africans, with only 7,4% of individuals covered, and highest in the white population, with a 66,5% coverage, Statistics SA said on Thursday. In the general population, 79,7% of those who were ill or injured consulted a health worker, according to the General Household Survey for 2007. The survey has been conducted annually since 2002. More individuals who used public-sector healthcare facilities were satisfied with the service they received in 2007 (87,6%) than in 2006 (84,2%) and in 2002 (81,6%). In the private sector, satisfaction levels increased slightly from 95,35% to 96,5% between 2002 and 2007.
Health minister Dr Manto Tshabalala-Msimang speaking at the Board of Healthcare Funders' annual conference stated that the private health sector has seen an uncontrolled cost spiral since the 1980s and that it has become increasingly unaffordable for South Africans to belong to medical schemes. She identified the most important cost drivers as private hospitals, specialists and administrative costs.
Global progress towards reducing undernutrition has been made through enlightened public policies, targeted development assistance, private sector actions and commitments from civil society. Yet every year, the deaths of more than 3.5 million children under the age of 5 can be attributed to undernutrition. This article argues that strong public-private sector partnerships can help to reduce undernutrition.
10. Resource allocation and health financing
This series of briefs provides a regional synthesis of findings of both the 12 thematic studies and the 20 individual case studies of social transfer schemes undertaken under the Regional Evidence Building Agenda (REBA). The themes explored in these briefs are the six addressed in the original REBA design: vulnerability, targeting, coordination and coverage, cost-effectiveness, markets, and asset protection and building. Each of these themes was covered by respective thematic studies in two of RHVP’s six priority countries, and was illustrated in each of the 20 case studies. Also included in the series are briefs on two additional themes that have emerged during the implementation of the REBA work as being of particular interest and policy relevance: delivery mechanisms and social pensions.
This study aimed at providing information for priority setting in the health care sector of Zimbabwe as well as assessing the efficiency of resource use. A general approach proposed by the World Bank involving the estimation of the burden of disease measured in Disability-Adjusted Life Years (DALYs) and calculation of cost-effectiveness ratios for a large number of health interventions was followed. Very cost-effective interventions were available for the major health problems. Using estimates of the burden of disease, the present paper developed packages of health interventions using the estimated cost-effectiveness ratios. These packages could avert a quarter of the burden of disease at total costs corresponding to one tenth of the public health budget in 1997. In general, the analyses suggested that there was substantial potential for improving the efficiency of resource use in the public health care sector. The present study showed that it was feasible to conduct cost-effectiveness analyses for a large number of health interventions in a developing country like Zimbabwe using a consistent methodology.
The first Millennium Development Goal - to eradicate extreme poverty and hunger - reflects the fact that undernutrition is both a symptom and a cause of poverty. In some cases, income is the main constraint to good nutrition, in some education, and in some both. Simply trying to educate the poorest families about good nutrition – a popular approach with development agencies for a long time – will not work if families do not have the money to put this knowledge into practice. Putting cash into families' hands can help to improve their diet. Save the Children UK's projects in Ethiopia show that when families are given small sums of cash, they spend it on more food and a better variety of food. It is likely that the impacts of cash transfers could be further multiplied if combined with nutrition education.
11. Equity and HIV/AIDS
HIV/AIDS funding to low- and middle-income countries reached a record level in 2007, according to a new report by UNAIDS. AIDS spending by the G8 group of wealthy nations, the European Commission and other donors hit US$ 6.6 billion last year, up from US$ 5.6 billion in 2006. However, despite the largesse, UNAIDS said a US$8.1 billion gap in funding for essential HIV/AIDS programmes remained.
Public health services are becoming increasingly important in Kenya, where more than 2.5 million people are living with HIV/AIDS. This paper in the International Journal for Equity in Health highlights the socio-economic impacts of HIV/AIDS on women. Two separate data sets from Western Kenya, one being quantitative and another qualitative data have been used. The authors argue that the socio-cultural beliefs that value the male and female lives differently lead to differential access to health care services. The position of women is exacerbated by their low financial base especially in the rural community where their main source of livelihood, agricultural production does not pay much. But even their active involvement in agricultural production or any other income ventures is hindered when they have to give care to the sick and bedridden friends and relatives. This in itself is a threat to household food security.
Failure to properly manage HIV strategies for employees has led to some workplace programmes being closed down, as audits have revealed unacceptable costs. Individual companies, communities and the South African economy are under threat if companies do not initiate expertly managed, independent and outsourced HIV programmes for their employees. Failure to expertly manage programmes effectively means money spent on them is wasted, with consequent negative impacts on the individuals concerned, and workplace productivity and morale. Companies that try to cut corners are reported to be undermining themselves, as well as the entire local treatment initiative.
The persistent and increasing outbreaks of violence against members of the gay community in Africa are jeopardising efforts undertaken to combat HIV, both within this group and across the population as a whole, AIDS activists warned at a recent meeting in Limbé, Cameroon. The extreme vulnerability of members of the gay community to HIV on the continent was highlighted during a meeting initiated by the French non-governmental organisation, AIDES, and its partners, which took place at the beginning of July in the south west of Cameroon. The meeting brought together many AIDS activists from Francophone African countries. On average it is estimated that HIV infection rates amongst MSM (men who have sex with men) are four to five times higher than the population overall.
Education contributes toward the knowledge and personal skills essential for the prevention of HIV, and the mitigation of the impacts caused by AIDS. Produced by the Joint United Nations Programme on HIV/AIDS (UNAIDS)'s Inter-Agency Task Team (IATT) on Education, this report synthesises case study exercises undertaken to examine the quality, effectiveness, and coordination of the education sector's response to the HIV epidemic in 4 countries - Jamaica, Kenya, Thailand, and Zambia. In each country, stakeholders assessed: critical achievements and gaps in the education sector response to HIV and AIDS; the evolution and effectiveness of coordination mechanisms and structures; progress toward harmonisation and alignment; information-sharing on HIV & AIDS and education; key resources for the response; and monitoring and evaluation. This report presents the overall findings from the study and makes recommendations for the IATT on Education and its partners to improve coordination in support of country level and to facilitate global actions.
The world's highest HIV infection rates are found in Sub-Saharan Africa (SSA), where adult prevalence in most countries exceeds 25%. Food shortages and malnutrition have combined with HIV/AIDS to bring some countries to the brink of crisis. The aim of this study was to describe prevalence of malnutrition among HIV-infected women and variations across socioeconomic status using data from 11 countries in SSA. Prevalence of HIV-related malnutrition among women varies by wealth status, education attainment, occupation, and type of residence (rural/urban). The observed socioeconomic disparities can help provide more information about population subgroups in particular need and high risk groups, which may in turn lead to the development and implementation of more effective intervention programmes.
The provision of highly active antiretroviral therapy (HAART) in resource-limited settings follows a public health approach, which is characterised by a limited number of regimens and the standardisation of clinical and laboratory monitoring. In industrialised countries doctors prescribe from the full range of available antiretroviral drugs, supported by resistance testing and frequent laboratory monitoring. This study compared virologic response, changes to first-line regimens, and mortality in HIV-infected patients starting HAART in South Africa and Switzerland. The study team analysed data from the Swiss HIV Cohort Study and two HAART programmes in townships of Cape Town, South Africa. Compared to the highly individualised approach in Switzerland, programmatic HAART in South Africa resulted in similar virologic outcomes, with relatively few changes to initial regimens. Further innovation and resources are required in South Africa to both achieve more timely access to HAART and improve the prognosis of patients who start HAART with advanced disease.
This report from the Centre for Health and Gender Equity outlines the importance of the female condom in preventing the spread of HIV. Female condoms are not readily accessible in most countries and significant investment is needed to overcome barriers to their use such as cost and difficulty of use, however the report finds that in the countries where they are accessible, there is a growing demand for them. The report concludes that high quality female condom programming is critical to increasing female condom demand and uptake. The role of the US government in these programmes is highlighted. The authors recommend policy changes that will promote the integration of female condoms into HIV prevention and family planning programmes within US funded development programs, including PEPFAR.
Prince Mshiyeni Memorial Hospital, just outside the port city of Durban, in KwaZulu-Natal Province, has one of South Africa's busiest maternity wards. About 1,200 women a month give birth there, of which about 40% are HIV-positive, according to figures from the antenatal clinic. For staff working in the hospital's antenatal clinic and maternity ward, implementing the government's new guidelines for the prevention of mother-to-child HIV transmission (PMTCT) has not been easy. HIV-positive mothers with CD4 counts over 200 should now receive zidovudine, also known as AZT, from their 28th week of pregnancy until labour, as well as a single dose of nevirapine during labour. Their infants should get a single dose of nevirapine, and then AZT for seven days (or four weeks if AZT was started late). The new drug regimen means extra work for the hospital staff, while the number of doctors, nurses and counsellors providing PMTCT services at the hospital has not increased. This article reports on the workload and facility issues that arise inimplementing the guidelines.
The primary purpose of this study was to assess the role, status and scope of workplace HIV/AIDS committees as a means of effective workplace governance of the HIV/AIDS impact, and their role in extending social protective HIV/AIDS-related rights to employees. In-depth qualitative case studies were conducted in five South African small and medium-sized enterprises (SMEs) that were actively implementing HIV/AIDS policies and programmes. Companies commonly implemented HIV/AIDS policies and programmes through a workplace committee dedicated to HIV/AIDS or a generic committee dealing with issues other than HIV/ AIDS. Management, through the human resources department and the occupational health practitioner often drove initial policy formulation, and had virtually sole control of the HIV/AIDS budget. Employee members of committees were mostly volunteers, and were often production or blue collar employees, while there was a notable lack of participation by white-collar employees, line management and trade unions. While the powers of workplace committees were largely consultative, employee committee members often managed in an indirect manner to secure and extend social protective rights on HIV/AIDS to employees, and monitor their effective implementation in practice. In the interim, workplace committees represented one of the best means to facilitate more effective workplace HIV/AIDS governance. However, the increased demands on collective bargaining as a result of an anticipated rises in AIDS-related morbidity and mortality might prove to be beyond the scope of such voluntary committees in the longer term.
Pages
12. Governance and participation in health
About 300 delegates representing organisations from across the drug policy spectrum met in Vienna for the Beyond 2008 NGO Forum, an effort to provide civil society input on global drug policy. Building on a series of regional meetings last year, the forum was part of an ongoing campaign to reshape the United Nations' drug policy agenda as the world organisation grapples with its next 10-year plan. The NGO meeting, which included drug treatment, prevention, education and policy reform groups, harm reduction groups and human rights groups from around the world, resulted in a resolution that will be presented to the UN Commission on Narcotic Drugs (CND) at its meeting in March 2009. At that meeting, the CND will draft the next UN 10-year global drug strategy.
From Poverty to Power, Oxfam International's new book, provides critical insights into the massive human and economic costs of inequality and poverty and proposes realistic solutions. It proposes that the best way to tackle them is through a combination of active citizens and effective nation states. Why active citizenship? Because people living in poverty must have a voice in deciding their own destiny, fighting for rights and justice in their own society, and holding states and the private sector to account. Why effective states? Because history shows that no country has prospered without a state structure than can actively manage the development process.
A dominant theme at DENIVA’S 4th International Conference on NGO Accountability, Self Regulation and the Law at Kampala was the shrinking space for civil society. This global trend is reported to be affirmed by the findings of the CIVICUS Civil Society Index, given the particular context of the global “war on terror”. Sadly, even in well-entrenched democracies, where civil society space was hitherto considered safe, there are negative trends. In current circumstances, it is critical that the international community remains alive to the steady roll back on civil society space and hard fought civil liberties across the world. This imperative is underscored by the economic meltdown in ‘western democracies’ where much of the funding for democratic reform and civil society initiatives comes from. Ensuring the sustainability of civil society organisations working on the advancement of health, human and democratic rights is one such means.
13. Monitoring equity and research policy
Scoping studies have been used across a range of disciplines for a wide variety of purposes. However, their value is increasingly limited by a lack of definition and clarity of purpose. The UK's Service Delivery and Organisation Research Programme (SDO) has extensive experience of commissioning and using such studies; twenty four have now been completed. This review article has four objectives; to describe the nature of the scoping studies that have been commissioned by the SDO Programme; to consider the impact of and uses made of such studies; to provide definitions for the different elements that may constitute a scoping study; and to describe the lessons learnt by the SDO Programme in commissioning scoping studies. Scoping studies are imprecisely defined but usually consist of one or more discrete components; most commonly they are non-systematic reviews of the literature, but other important elements are literature mapping, conceptual mapping and policy mapping. Some scoping studies also involve consultations with stakeholders including the end users of research. Scoping studies have been used for a wide variety of purposes, although a common feature is to identify questions and topics for future research. The reports of scoping studies often have an impact that extends beyond informing research commissioners about future research areas; some have been published in peer reviewed journals, and others have been published in research summaries aimed at a broader audience of health service managers and policymakers. Key lessons from the SDO experience are the need to relate scoping studies to a particular health service context; the need for scoping teams to be multi-disciplinary and to be given enough time to integrate diverse findings; and the need for the research commissioners to be explicit not only about the aims of scoping studies but also about their intended uses. This necessitates regular contact between researchers and commissioners. Scoping studies are an essential element in the portfolio of approaches to research, particularly as a mechanism for helping research commissioners and policy makers to ask the right questions. Their utility will be further enhanced by greater recognition of the individual components, definitions for which are provided.
It appears that the practice of giving cash or gift vouchers to research participants is becoming increasingly common; however, this practice has received little attention from social researchers. Paying participants has implications in terms of the ethical requirement for consent and may have consequences in terms of recruitment for research projects and for the data collected. In this paper the author considers how these issues arose in a research project with lone mothers and the way in which offering payments might help with gaining access to participants. She argues that the possible impact of making payments to research participants should be considered in research accounts and the possible impacts of payments should be more widely debated.
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. The Lived Poverty Index is strongly related to the measurement of political freedoms, according to this study. It 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.
14. Useful Resources
Community-Led Total Sanitation (CLTS) is a participatory process focused on promoting change in sanitation behaviour through social action - stimulated by facilitators from within or outside the community. Aimed at empowering local communities this handbook is a source of ideas and experiences to be used for CLTS orientation workshops, advocacy to stakeholders as well as for implementing CLTS activities. It is intended as a tool for field staff, facilitators and trainers to plan, implement and follow up on CLTS activities.
The new Europafrica.org website has been launched. It presents news and resources on the Joint Africa-EU Strategy and its Action Plan.
The new HIFA2015 website was launched on the 1st July 2008 and addresses the knowledge gap in health provision in developing countries. The aim is to develop this site substantially over the coming months - especially the
HIFA2015 Knowledge Base section.
The International AIDS Alliance has produced a resource to help service providers working across the spectrum of HIV prevention, treatment, care and support services to take steps towards integrating HIV prevention for, by and with people living with HIV (PLWHA). The guide does not discuss or review all HIV prevention strategies and focuses largely on the sexual transmission of HIV. It consists of 15 strategies arranged into four themes including individually focused health education and support; ensuring access, scaling up and improving service delivery; community mobilisation and advocacy and policy change. For each section the guide details issues to consider including the most sensitive ways of dealing with HIV status disclosure; how best to provide information about testing, counselling and treatmentand how to facilitate post test clubs and support groups.
15. Jobs and Announcements
This annual event brings together scientists, public health experts, clinicians, epidemiologists and members of the corporate sector. The conference aims to encourage a strategic plan for HIV vaccine research, funding and greater collaboration in the field.
Organised by the national branch of the Southern African HIV Clinicians Society, the conference will give new insights into HIV treatment regimens and initiatives to reduce HIV transmission.
The UPEACE Africa Programme has secured funding from the Canadian International Development Research Centre (IDRC). This funding will be strictly allocated to African students studying at African institutions and, in particular, for those who are in the final stage of their PhD studies. The award is intended to support PhD candidates in their field research, data analysis, associated travel and production costs. In addition, part of the award may be used to access updated scholarly materials and disseminate research findings through publications and conference presentations. The maximum award is US$10,000 per eligible student. The deadline for applications is 12 September 2008.
The conference is the first in a planned series of bi-annual conferences on child rights, social justice and equity that aims to: contribute to the attainment of child rights through sharing of ideas, research findings and good practices; strengthen the collaboration between researchers, practitioners and policy makers working on children's issues; and encourage innovative research in "under-researched" areas.
This call for "Incentives to Attract and Retain Qualified Health Workers to Under-served areas within Low- and Middle-income Countries" is issued in collaboration with the Human Resources for Health Department of WHO and is intended to support pragmatic and policy oriented research that either enhances understanding about factors that influence health workers choice of practice location, and/or the feasibility and effectiveness of practical measures to influence health worker location. A total of US$500,000 is also available to support proposals under this call. The closing date for the call is 12 September 2008. The call is only open to applicants in low- and middle-income countries.
This call for "Supporting National Processes for Evidence-informed Policy in the Health Sector of Developing Countries" is intended to promote a variety of possible strategies that strengthen evidence-to-policy links. A total of US$500,000 is available to support proposals under this call. The closing date for the call is 12 September 2008. All applicants must be based in low- or middle-income countries. Teams composed of different organisations and actors (such as policy-makers, research institutions, think tanks, civil society representatives and knowledge brokers) are particularly welcome to apply.
African health and environment ministers will gather for the first time from 26 to 29 August, 2008, in Libreville, Gabon to enhance political commitment and investments for reducing environmental threats to health. The First Inter-Ministerial Conference on Health and Environment in Africa will be hosted by the Government of Gabon, together with WHO and the United Nations Environment Programme. Participants will come from health and environment ministries, multilateral and bilateral agencies, media, non-governmental organizations and civil society. The conference will explore ways to address key priorities and links in line with its theme “Health security through healthy environments”. It will review existing mechanisms and opportunities to address environmental challenges facing Africa. An agreement on specific actions required for changes in institutional arrangements and investment frameworks will be discussed.
This workshop aims to highlight and share best practice lessons that will improve policy, practice and implementation on HIV programmes. The workshop targets senior staff in organisations that operate in the AIDS sector.
Médecins Sans Frontières (MSF) invites all interested parties to attend a satellite meeting on the impact of the health care worker shortage on access to HIV/AIDS treatment and lessons learned from clinicians and advocates working on the ground to overcome this gap. Date: August 3, 2008, 9am - 1pm. Venue: Melia Reforma Hotel, Paseo de la Reforma, Mexico City, Mexico.
Oxfam is organising a two-hour round-table discussion for sharing thoughts and ideas and initiate a debate on health insurance, which gained significant importance on the political agenda recently as a way of financing health care. The workshop will call for the participation of different stakeholders among them are governments, international organisations and civil society organisations. The workshop will be organised at the XVII International Aids Conference in Mexico (date of discussion: 4th of August, 17.00-19.00). It is a good opportunity to share experiences and knowledge on health insurance as it is being implemented and promoted in several countries, as well as the risks that need to be taken into account with regard to the goal of achieving universal coverage, equity and access for all.
Pages
Published by the Regional Network for Equity in Health in east and southern Africa (EQUINET) with technical support from Training and Research Support Centre (TARSC).
Contact EQUINET at admin@equinetafrica.org and visit our website at www.equinetafrica.org
Website: http://www.equinetafrica.org/newsletter
SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to editor@equinetafrica.org Please forward this to others.
SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org or send an email to info@equinetafrica.org
This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact editor@equinetafrica.org immediately regarding any issues arising.