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
Tanzania is one of the countries hardest hit by the HIV/AIDS epidemic. The Tanzania Commission for AIDS was established as part of the government response to the HIV epidemic. This manual is part of the Tanzania Commission for AIDS strategic plan to coordinate and strengthen the efforts of stakeholders involved in the fight against HIV/AIDS. It is intended as a training manual for local government authorities.
The AIDS epidemic is a disaster on many levels. In the most affected countries in sub-Saharan Africa, where prevalence rates reach 20%, development gains are reversed and life expectancy may be halved. For specific groups of marginalized people injecting drug users, sex workers and men who have sex with men across the world, HIV rates are on the increase. Yet they often face stigma, criminalization and little, if any, access to HIV prevention and treatment services. As this report explains, HIV is a challenge to the humanitarian world whose task is to improve the lives of vulnerable people and to support them in strengthening their capacities and resilience. Disasters, man-made and ‘natural’, exacerbate other drivers of the epidemic and can also increase people’s vulnerability to infection.
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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
Progressio is currently advertising a new vacancy based in Lilongwe, Malawi. The position of HIV and AIDS advocacy adviser (two-year placement) is available, where you will be working alongside the Malawi Interfaith AIDS Association (MIAA) and the Malawi Network of Religious Leaders living with or personally affected by HIV and AIDS. Contact Ricardo Tomaz, Recruitment, selection and training coordinator, at: Progressio, Unit 3, Canonbury Yard, 190a New North Road, London N1 7BJ, United Kingdom. Tel: (44) (0) 20 7354 0883 (switchboard) Fax: (44) (0) 20 7359 0017. Note that Progressio is the new name of the Catholic Institute for International Relations (CIIR).
A social scientist/demographer/epidemiologist is sought to play an important role in a large Wellcome Trust-supported research programme based in northern Malawi. The programme includes demographic surveillance in a population of 32,000, and an HIV and sexual behaviour survey. This represents an unusual opportunity for involvement in a major long-term programme. The closing date for applications is 27 August 2008.
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