“I started volunteering [as a community health worker] in 1996. During that time, the most common disease in my village was tuberculosis (TB). We worked together and visited those who were infected with TB. We also went to fetch their pills from hospital and distributed them accordingly. We were to ask the sick people to cough out the sputum and save it inside specimen bottles that we took to a certain sister at the hospital.” (Eastern Cape community health worker)
Community members have been rendering certain basic health services to their communities for at least 50 years. All over the world, but particularly in countries in Asia, Africa, and Latin America community or village health workers (CHWs) have been providing health education to their communities, helping pregnant mothers and new-born babies and treating basic illnesses. They are often mature women, with little formal education. The quotes from CHWs in Eastern Cape South Africa highlight this experience.
“My first encounter with the health programmes was in 1986. Our training was to help people who had been swept by the river waters and nearly drowned. ….We went to all the homes teaching people about TB and how to avoid it. To those who had it already we continued to train them on how to take care of themselves and prevent further spreading of the disease. We encouraged people to have toilets, to build chicken runs and pig sties and avoid animals running loose all over the place to keep ourselves in good health.” (Eastern Cape community health worker)
Since the arrival of HIV, community health workers have also been counselling community members, providing peer support and home-based care and ensuring that people on antiretroviral therapy take their treatment. In some countries they have also been involved with HIV testing.
In the past CHWs have been seen as advocates for health in their communities and agents for social change. This made them central to comprehensive primary health care. In recent years a much more technical understanding has taken hold, which views CHW programmes as a strategy to address health worker shortages in most countries. This view is reflected in the 2006 World Health Report which advocates the delegation of tasks to lay health workers.
The renewed enthusiasm for community health workers presents great opportunities to seriously review how community health is organized and rendered and to empower communities. However, questions have to be asked about the rationale and intention of this enthusiasm:
• Is it realistic to expect commununity members from invariably impoverished communities to take responsibility for what in effect are essential health services, often with very little training and hardly any supervision?
• Are governments in fact not abdicating their responsibility for ensuring appropriate health care for their citizens, in particular the most vulnerable ones?
• Under what circumstances are CHW programmes empowering communities and under what circumstances are they shifting the burden of health care to those most vulnerable in society?
• What roles can CHWs realistically play?
There is ample rigorous evidence from different parts of the world that CHWs can play a crucial role in broadening access and coverage of health services in remote areas and can undertake actions that lead to improved health outcomes in a range of areas, including child health, TB and HIV/AIDS care. CHW programmes hold the potential of enabling countries to build sustainable, cost-effective and equitable health care systems, thus contributing towards moving closer to achieving the Millennium Development Goals. However, the challenge of achieving success cannot be underestimated. Programmes need careful planning, secure funding and active government leadership and community support. To render their tasks successfully, CHWs need regular training and supervision and reliable logistical support. Importantly, governments have to retain their responsibility for essential health services at all levels, including for CHWs programmes. It is their responsibility to ensure that CHWs are, in fact, appropriately and adequately trained and supported by health service staff and communities and that their roles are clearly understood by all role players. This requires political leadership and substantial and consistent resourcing.
Given present pressures on health systems and their proven inability to respond adequately, the existing evidence strongly suggests that, particularly in poor countries, while CHW programmes are not easy, they are a good investment. This is particularly true given that the alternative in reality is NO care for the poor living in geographically peripheral areas.
They represent far more than improved service provision and access, however.
The continued testimony from the community health worker in South Africa’s rural Eastern Cape province demonstrates the personal and social dimensions of health actions that CHWs bring:
“Then the disease called HIV/AIDS started attacking people till it came to my house and attacked my own son. I could not understand this disease which he came with from Cape Town, but I took him to hospital. I was very hurt and heartbroken to see how his whole body was covered with sores, from head to toe, even the softest parts. I took him to hospital. At the hospital I was not told that it was HIV/AIDS, I was told he had TB. After reading his forms carefully, because I could read a little, I discovered that they had diagnosed him with thing [HIV/AIDS]. My frustration worsened, and that is when I decided to give myself to the whole of the village to help other people, especially that I had this bad experience firsthand. I went up and down the ravines of the village working. Many more people were discovered to be infected till this day. I worked harder and harder though, unfortunately, some of those I tried to help could not make it, they died. Some had very bad sores and we frequently washed them. I would take a flask from home and boil water for my patients to keep in it so I could prepare something to eat for them before taking their medication. For some, I would get there and start making fire with wood as we normally do in the rural areas, and warm water to use for his bath. They looked very bad during those days but today you wouldn’t think it’s the same person that I had nursed to recovery” (Eastern Cape community health worker).
1. Editorial
Village health workers (VHWs) were key to Zimbabwe`s successful expansion of primary health care (PHC) in the early 1980s. They played a central role in closing the gap between public health services and communities at local levels, bringing health services outreach to communities, and facilitating community roles in the health delivery system. For example, village health workers and community based distributors were instrumental in implementing the successful Zimbabwe Family Planning Programme, as they helped raise awareness on family planning methods such as condoms and combined oral contraceptives (commonly known as ‘the Pill’), as well as the advantages of child spacing. These efforts are reflected in the expansion of coverage of contraception and reported decrease in fertility rates in the country from 6.5 children per woman in the early 1980s to 4.3 children per woman in 2001.
VHWs continue up to today to augment the work being done by the mainstream health sector: raising awareness, giving health advice, monitoring growth of children under five years, and mobilising communities during out-reach programmes and for immunisation. Mrs. Kaseke a VHW in Mwanza ward (Goromonzi district) echoes these sentiments. One of her roles as a VHW is to mobilise food for chronically ill and home based patients in her area. She also runs community-based growth monitoring clinics on Saturdays. ‘I have a scale that was allocated to me by the clinic when I started as a VHW. Women from my area bring their babies to my homestead. I weigh the babies and record their weight on cards, as it is done at the clinic. I then use the weight records to check if the child is growing well; otherwise I refer the child to the clinic for further assessment’.
VHWs see an important role for themselves in bridging the gap between the community and the health services, as explained by another VHW from Gokwe South District, Musatyanika Wushe: ‘We are the link between the community and the health department. We advise and refer the community to seek medical attention early, care for home-based ridden patients, and chronic and TB patients on DOTS’.
Despite these vital functions, the numbers of VHWs and the role played by VHWs has diminished over the past two decades in Zimbabwe. While communities cite low morale due to lack of incentives as the major setback, the VHWs and other health staff point to lack of incentives and supporting resources and protective equipment as a major barrier to their performance.
In their early years, VHWs benefited from incentives such as uniforms, bicycles and allowances, which were meant to enhance their work and motivate them. Bicycles were both a token of appreciation and a tool to enable these volunteers to take their services to a wider population. The allowances they received helped them to buy basic necessities such as soap, so that they could look presentable while they carried out their duties. These incentives are now a thing of the past; and the remaining cadres are at times compelled to use their own resources to ensure that they can continue to serve their communities.
Highlighting the plight of VHWs, Mr. Wushe said, ‘We, as village health workers, are surprised about how we are handled. The problem is, out of all these duties, our allowances are still as low as ZW$20,000 (about US$0.01) per month, which is received after 12 months. One may be surprised to hear that allowances for December 2006 were received on the 26 of November 2007! We are very much exposed to the world of infection because we do not have protective clothing to put on when attending to home-based patients, most of which may have open wounds. From 2002 up to now ,we have tried in vain to request this protective clothing from our district hospital but the response is disheartening’.
In addition to the resource gaps for VHWs, there have also been some changes in roles and responsibilities that have affected their work on health. During the period 1988-1999, the government introduced a multi-purpose cadre, the ‘village community worker’ (VCW). They were introduced under the Ministry of Political Affairs to take up a number of roles, including taking over some roles previously implemented by VHWs. However, unlike the VHWs, VCWs were political appointees, appointed by the ruling party leadership and then employed and trained by the Ministry of Political Affairs. This reporting and accountability structure weakened the link between the community and the health authorities. After calls by communities for the re-introduction of VHWs, the Community Working Group on Health (CWGH), among other civil society groups, lobbied government through the Ministry of Health and Child Welfare to re-introduce this cadre. VHWs were subsequently re-introduced in Zimbabwe in 2001 and over 2,000 VHWs were trained across the nation. While this has been welcome, there is still need to address the barriers to their morale and functioning.
VHWs have been proposed as one measure to deal with a gap in health worker numbers. While they cannot replace adequately trained staff at primary and district levels of health systems, they are a key cadre in the health system because they are aware of the health needs and aspirations of their communities. This makes them an invaluable asset in advancing community-orientated health delivery and they should be supported. Although the 2008 national health budget in Zimbabwe had a sizable allocation towards VHWs, meetings held in 25 districts where CWGH is operating suggested that this budget is yet to reach the cadres on the ground. The CWGH has thus urged government to work with other stakeholders to create a plan to fully revive the VHW programme, support their work and ensure that resources allocated in the budget for VHWs reach them.
This is not just a matter for government. As part of civil society, we see that the presence of VHWs in our communities is essential in our quest for equity in health and accessibility of health services. We too need to be part of this support. Towards this end, CWGH will be documenting the roles and impacts of VHWs in our communities to engage government and other stakeholders to value and resource these roles in the spirit of health for all.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. The CWGH is a network of membership based civic organisations focusing on advocacy, action and networking around health issues in Zimbabwe. www.cwgh.co.zw
2. Latest Equinet Updates
The Third EQUINET Regional Conference on Equity in Health in East and Southern Africa will take place at the Speke Conference Centre, Munyonyo, Kampala, Uganda, 23-25 September 2009. This is a unique opportunity to hear original work and debate on the determinants and forces that are driving or impeding equity in health in east and southern Africa, including those at global level. Visit the conference website at http://www.equinetafrica.org/conference2009/index.php. The conference will have plenary and workshop/ parallel sessions on: * Health equity in east and southern Africa; * Protecting health in economic and trade policy; * Building universal, primary health care oriented health systems; * Equitable, health systems strengthening responses to HIV and AIDS Fair Financing of health systems, and reclaiming financial resources for public sector health services; * Valuing and retaining health workers; * Organising participatory, people centred health systems; Social empowerment and action for health; Understanding and managing equity oriented policy development and implementation; * Country experiences of advocacy and promotion of equity in health; and Monitoring progress through country and regional equity watches. A call is made for proposals for pre- and post-conference skills and theme workshops to be sent to the Conference Scientific Committee before 25 September 2008. Workshops are anticipated to be one day or half-day sessions and to include about 30 people. Accepted workshops will be listed in October 2008.
The Tanzanian public health sector is losing workers to internal and external migration. This paper examines the implementation of policies to govern non-financial incentives to retain health workers. It outlines a range of non-financial incentives set in policy in Tanzania, including training; leave; promotion; housing; and a safe and supportive working environment. It also examines the systems for managing personnel and the implementation of incentives as a factor in retention, including the participatory personnel appraisal system; worker participation in discussing their job requirements and welfare; supervision; recognition and respect. Drawing on a review of policy, published and grey literature and on a field study of seven districts, including five underserved districts, the paper finds that while a number of incentives exist in policy, their sustainability is eroded by the absence of special earmarked funding for their implementation.
Partners in Population and Development, Africa Regional Office (PPD ARO) the Regional network for Equity in Health in East and Southern Africa (EQUINET), African Population Health Research Centre (APHRC) and Alliance of parliamentary committees on Health in east and southern Africa (SEAPACOH) are jointly organizing a meeting in Kampala, Uganda on September 16-18 2008. The meeting will invite MPs drawn from Parliamentary Committees responsible for health as well as technical, civil society and regional partners. The meeting will review the health equity situation assessment in the region, including in relation to regional and international goals; review and discuss sexual and reproductive health, HIV and AIDS, population policies, laws and budgets; discuss options for fair and adequate health care financing and for promoting equitable resource allocation, particularly in relation to budget processes; explore the application of international and regional treaties and conventions on the right to health; update on current health and trade issues and legal frameworks for ensuring protection of public health; discuss developments in primary health care and essential health care and review and make proposals to strengthen SEAPACOH and parliamentary committee regional networking. For more information on the meeting please contact us at admin@equinetafrica.org
SEATINI / EQUINET are holding a workshop bringing together civil society, parliamentarians, human rights commissions, trade and health ministries officials to review and deliberate on protection of health and access to health care services in the ongoing EPA negotiations, and particularly in the services negotiations. The meeting will be held in Kampala Uganda September 18-19 2008. The meeting aims to:
* Update on current health and trade issues, including patenting laws and the EPA negotiations and more generally legal frameworks for ensuring protection of public health in trade agreements.
* Review the technical analysis report developed looking on the services negotiations in the Economic Partnership Agreements.
* Review and develop key positions to be advanced for the protection of public health in trade agreements and strategies for advancing them.
* Develop progress markers with regards to the EPA negotiations and protection of public health.
* Develop a workshop declaration.
For any queries please email admin@equinetafrica.org
3. Equity in Health
The Final Report of the Commission on Social Determinants of Health sets out key areas of daily living conditions and of the underlying structural drivers that influence them in which action is needed. It provides analysis of social determinants of health and concrete examples of types of action that have proven effective in improving health and health equity in countries at all levels of socioeconomic development. Part 1 sets the scene, laying out the rationale for a global movement to advance health equity through action on the social determinants of health. It illustrates the extent of the problem between and within countries, describes what the Commission believes the causes of health inequities are, and points to where solutions may lie. Part 2 outlines the approach the Commission took to evidence, and to the indispensable value of acknowledging and using the rich diversity of different types of knowledge. Parts 3, 4, and 5 set out in more detail the Commission s findings and recommendations. The chapters in Part 3 deal with the conditions of daily living the more easily visible aspects of birth, growth, and education; of living and working; and of using health care. The chapters in Part 4 look at more structural conditions social and economic policies that shape growing, living, and working; the relative roles of state and market in providing for good and equitable health; and the wide international and global conditions that can help or hinder national and local action for health equity. Part 5 focuses on the critical importance of data not simply conventional research, but living evidence of progress or deterioration in the quality of people s lives and health that can only be attained through commitment to and capacity in health equity surveillance and monitoring. Part 6, finally, reprises the global networks the regional connections to civil society worldwide, the growing caucus of country partners taking the social determinants of health agenda forward, the vital research agendas, and the opportunities for change at the level of global governance and global institutions that the Commission has built and on which the future of a global movement for health equity will depend.”
This review examines the impact of global health initiatives (GHIs) on health equity, focusing on low- and middle-income countries. It is a summary of a literature review commissioned by the WHO Commission on the Social Determinants of Health. GHIs have emerged during the past decade as a mechanism in development assistance for health. The review focuses on three GHIs: the US President’s Emergency Plan For AIDS Relief (PEPFAR), the World Bank’s Multi-country AIDS Programme (MAP) and the Global Fund to Fight AIDS, TB and Malaria.
The public health sector in South Africa has come under criticism over poor services and the failure to implement government policies effectively. The past 14 years have seen a widening gap between the private and the public health care sectors with the latter struggling to provide quality service, thus making it difficult for most South Africans who don’t belong to medical aid schemes to access quality health care. Advocate Khaya Zweni, a lawyer with the Human Rights Commission (HRC), says most are not happy with the service offered by public health care institutions. Following numerous complaints from the public, the Human Rights Commision conducted a survey in more than 90 public health institutions countrywide. Dr Anban Pillay, the Department of Health's cluster manager for health economics, believes that the problems in health delivery could be dealt with if the department is allocated a bigger budget by Treasury. ‘The problem with the public sector relates to a lack of funding. That lack of funding needs to be corrected. We are currently at the 11% of government expenditure on health care. We need to get around 15%. That’s what the government needs to do,’ Pillay said.
The United Nations Children’s Fund (UNICEF) and the World Health Organisation (WHO) is urging increased support for breastfeeding mothers since the practice has been shown to slash deaths by more than 10% in infants in developing countries. Despite advances in the past 15 years, only 38% of infants under six months of age in the poorer nations are exclusively breastfed, a practice which could curb infant mortality. Various studies have shown that the number of months which mothers breastfeed – especially exclusively – can be extended by education and support. The practice can reduce the number of deaths caused by acute respiratory infection and diarrhoea, as well as other infectious diseases. It also improves mothers’ health and strengthens the bond between mother and child. ‘There is a double message here: it is not enough to say that breastfeeding is an ideal source of nourishment for infants and young children; mothers also need support to make optimal breastfeeding practices a reality,’ WHO Director-General Margaret Chan said.
4. Values, Policies and Rights
Although the ethical principles of justice, beneficence and respect for autonomy/persons should be upheld in research, their application in emergency situations may differ from non-emergency situations. Just like in non-emergency situations, research in emergency situations should be conducted in the best interest of the victims or future victims. The research should not unnecessarily expose human subjects and the researcher to careless harm, and should be of adequate scientific rigour. Victims of emergency situations are vulnerable populations that need special protection from exploitation. Researchers should conduct a fair risk-benefit assessment in order to come up with a risk management plan, and be culturally sensitive to the needs of the victims of the humanitarian crisis. In emergency situations, the roles of Institutional Review Boards (IRBs) may have to be modified without compromising the ethical standards that health researchers have globally attempted to achieve.
In this article, the author takes a rights-based view of the current crisis of restricted access to the results of scientific and medical research. Such research is conducted in the interests of the public, and yet the results are largely kept out of the public domain by traditional corporate publishers who own them, subject them to extremely tight copyright restrictions and sell them in a market worth about US$5 billion annually. The results of biomedical research have unfortunately been privatised, monopolised, and concentrated in the hands of a tiny number of multinational corporations.
This paper provides arguments for discussions about the role of property rights for food security and child nutrition in rural Africa. The results are drawn from a case study in the Kafue Flats of Zambia. They show that unclear jurisdictional boundaries and weak authorities facilitated re-negotiations of property rights related to natural resources in the context of the Southern African food crisis of 2002–2003. Access to natural resources was skewed towards the more powerful. On average, food intake was temporarily 50% lower than the annual mean, compared to a less than 10% decrease in the lean season of 2003–2004. Large inequalities existed between different clusters of villages, according to the history of immigration and ethnicity. Yet variability was greatest within villages. Households which reported increasing difficulties with access to natural resources had less diversified income-generating activities, lower food intake and more children showing impaired growth. Discussions addressing the growing disparities in rural areas should focus on a realistic implementation and enforcement of property rights in the context of local power-relations and the harmonisation of different tenure systems related to natural resources.
This booklet addresses the benefit of treating sanitation in human rights terms,the legal basis of the right to sanitation, state obligations and standards for differing environments, and priority actions for governments and other stakeholders. While there has been some progress on the recognition and implementation of the right to water, the same is not true of sanitation services. The current International Year of Sanitation presents an opportunity to address the lack of attention paid to sanitation and hygiene in human rights terms. This publication is a call to recognise sanitation as a crucial aspect of the right to an adequate standard of living, setting out the most important strategies and measures that stakeholders and decision-makers can prioritise in order to ensure that sanitation is accessible and affordable to all. It is an advocacy tool to encourage more funding for sanitation, more debate and more research into the barriers to accessing affordable sanitation and how to remove them.
This paper describes how maternal and neonatal mortality in the developing world came to be seen as a public-health concern, a human rights concern, and ultimately as both, leading to the development of approaches using human rights concepts and methods to advance maternal and neonatal health. It describes the different contributions of the international community, women's health advocates and human rights activists.
5. Health equity in economic and trade policies
The World Trade Organisation Doha Round talks ended bitterly on 31 July, but negotiators left town with the general consensus that hard-earned work to date should not be lost and that there might be resumption of talks sometime in the future. The fate of intellectual property (IP) issues at the WTO remains vague and may not come clear for weeks or months, according to some sources, while others said it will be business as usual for international trade rules on IP.
This article suggests that the recent collapse of the WTO mini-ministerial, July 2008, reflects the new geopolitics of the global economy. The emerging economies are approaching trade issues and negotiations differently. Particularly they place more emphasis on supporting women employed in agriculture. There is new conviction among negotiators that poverty and livelihood issues cannot be left to the market to be regulated. These concerns contributed to the collapse alongside the Special Safeguard Mechanism (SSM) issues. The paper emphasises that the political value of technical issues should not be ignored. Reasons for this and for why the SSM was not the only reason for the collapse include:import surges of subsidised products could displace millions of people, giving the SSM major political value; the G33, the G7 and the G20 could not find a common position in discussions on the SSM; cotton, a highly politically contentious issue, was due to be discussed after the SSM and was likely to have caused problems; and agricultural market access discussions reflected a political choice that links growth to market access and ‘offensive interests’. In conclusion the paper notes: the context of the Uruguay Round no longer exists as the emerging economies now have a voice; there may be increasing use of the Dispute Settlement Body.
As the push toward neoliberalism advances, and quantitative measures to protect local markets, such as tariffs and quotas, disappear, industrial powers are turning to qualitative measures such as food safety regulations to further skew trade in their favour. In the food safety arena, both the US and the EU are pressing their standards on other countries. For Washington, even though its own food safety system is widely criticised as too lax, this means getting countries to accept GMOs and US meat safety inspections. For Brussels, whose food safety standards have a much better reputation, it means imposing high standards on countries that cannot meet them. Bilateral free trade agreements (FTAs) have become a tool of choice to push through the changes.
‘Neoliberalism’, has guided the globalisation of economic activity and become the conventional wisdom in international agencies and institutions (such as the IMF, World Bank, World Trade Organisation and the technical agencies of the United Nations, including the WHO). Reproduced in the ‘Washington Consensus’ in the United States and the ‘Brussels Consensus’ in the European Union, this ideology has guided policies widely accepted as the only ones possible and advisable. This book assembles a series of articles that challenge that ideology. Written by well-known scholars, these articles question each of the tenets of neoliberal doctrine, showing how the policies guided by this ideology have adversely affected human development in the countries where they have been implemented.
Intellectual property is the last real comparative advantage that rich countries have, said a panellist at a recent International Centre for Trade and Sustainable Development (ICTSD) and UN Conference on Trade and Development (UNCTAD) joint event. This may explain an increasing global drive for enforcement of these rights, but does not mean that such enforcement is necessarily good for developing countries.
The round table on ‘Conceptual and Operational Issues of Lender Responsibility for Sovereign Debt’ was hosted by the World Bank following the publication of a draft World Bank discussion paper entitled ‘Odious debt: Some considerations’ in September 2007. The event was organised in response to a request by a coalition of civil society organisations (CSOs) interested in discussing the findings of the bank’s paper and the broader issues of odious/illegitimate debt and responsible lending. This outcome report captures some of the main points raised by panellists as well as the discussions with the meeting’s participants which followed, namely, the concepts of odious and illegitimate debt, whether or not these can be considered well-established legal concepts, consideration of how feasibly these concepts could be applied in practice and practical approaches to addressing concerns on responsible lending and borrowing in the future. As follow-up some civil society organisations suggested that, if the World Bank was indeed serious about the importance of the odious debt issue, it should foster further discussions on the subject with legal experts to discuss different approaches to dealing with the problem. It was also proposed that the World Bank and a Southern CSO jointly appoint an independent auditor to examine selected credit according to mutually agreed indicators. Finally, CSOs called for the World Bank discussion paper and roundtable outcome report to be discussed by the bank’s management and Board.
A SADC Task Force of Ministers of Trade, Finance and Agriculture met on 13 July 2008 in Lusaka, Zambia to discuss measures to mitigate currently increasing food prices, the impending food crisis and ways to improve the food security situation in the SADC region. The Ministerial Task Force noted that prices of food commodities worldwide have risen sharply over the past couple of years and even more sharply from January 2007 to date. There are a number of factors that are believed to contribute to the observed increase in world food prices. Key among them are the increasingly poor weather conditions, high energy prices, worldwide reduction in levels of food stocks, massive shift in crop cultivation towards bio-fuels, increased consumption of food in emerging economies such as India and China, commodity speculation, and inadequate investment in agriculture in recent decades. However, prices in the SADC region haven’t risen quite as sharply as world prices, which provides for a window of opportunity for measures to be taken for minimising future rises in food prices. The Ministerial Task Force came up with several measures the Member States and the SADC Secretariat should take in order to reduce current and future food crises in the region. These include: increasing the levels of investment in agriculture, including aligning national budgets to the 10% of national budgets agreed to by SADC Heads of State and Government in May 2004; improving access to agricultural inputs especially fertiliser through the provision of temporary subsidies to smallholder farmers; expediting the harmonisation of Sanitary and Phyto-sanitary Standards measures and removal of non tariff barriers within the region; encouraging financial institutions and NGOs to prioritise agriculture and extend credit to small scale farmers especially women and vulnerable groups; introducing social security systems targeted at the vulnerable to cushion them from the impact of increased food prices; facilitating easy flow of information among Member States and with SADC Secretariat; facilitating the establishment of a Regional Food Reserve Facility; and creating appropriate incentives for private sector involvement in services related to agricultural and food security.
One of the main agenda items of the 2008 SADC Summit is the launch of the Free Trade Area. Having completed the critical tasks of the SADC Trade Protocol, the SADC FTA was launched during the Summit on 17th August 2008 under the theme: “SADC Free Trade Area for Growth, Development and Wealth Creation”. SADC attained the Free Trade Area as of January 2008, although three of its Member States, namely Angola, DRC and Malawi are still addressing challenges facing them in the implementing the Protocol on Trade. The region was also reported at the Summit to have recorded significant progress and positive developments in the core areas of social and human development. In the health sector, positive results were recorded in combating HIV and AIDS, Malaria and Tuberculosis. Measures were put in place to increase access to preventive and curative services. Consequently, prevalence and incidence rates for HIV and Malaria declined in certain population categories and some parts of the region, with a decline in both prevalence and incidence of HIV especially among the youth aged 15 to 24 years and pregnant women attending ante-natal clinics. A 90% reduction of malaria incidence was recorded in countries in the Lubombo Spatial Development Initiative where malaria cross border control initiatives are being implemented. These emerging positive indicators are due to improvements and strengthening of health systems in Member States.
6. Poverty and health
The new edition of the annual Food Aid Flows report provides a comprehensive view of trends in global food aid, which include food aid deliveries by governments, non-governmental organisations and the World Food Programme. It shows that food aid deliveries continued to decline in 2007, reaching the lowest level since 1961. The report argues that there is an urgent need to reverse this trend. In particular, increased resources for food assistance are urgently needed to address the serious negative effects of the higher food prices on hunger and malnutrition across the world. The report provides data of food aid flows in 2007 by category, mode, channel, sale recipient, region and donor. Key trends identified in 2007 include: food aid deliveries reached a record low in 2007, with all three categories of food aid – emergency, project and programme – declining. The share of food aid that was channelled multilaterally continued to increase and reached 55%, the highest share ever. The share of food aid commodities procured in developing countries increased but there was a decline in direct transfers of wheat and maize, which can be partly explained by higher wheat and maize prices. Of 31 main government donors, 24 reduced their food aid donations in 2007 as all regions faced a decline in food aid deliveries in 2007, except Asia. Sub-Saharan Africa remained the largest recipient of food aid. Based on these findings, the report emphasises the need for increased food assistance, particularly in the context of recent food price rises. Given that food prices are expected to remain high during the next decade, it argues that, without additional interventions, higher food prices could jeopardise the prospects for the achievement of Millennium Development Goals and the fight against hunger and malnutrition.
A combination of new and ongoing forces is driving global food prices up. Recent studies in Botswana, Swaziland, Malawi, Zambia and Tanzania have shown associations between acute food insecurity and unprotected transactional sex among poor women. Sudden increases in food insecurity often lead to ‘distress migration’ as people search for work and food. Mobility is a marker of enhanced risk of HIV exposure and food insecurity at the household level is likely to translate over time into higher rates of adult malnutrition with possible detrimental effects on immune status.
While there has been widespread reporting of the riots that have broken out around the world as a result of the global food crisis, little attention has been paid to the way forward. The solution is a radical shift in power away from the international financial institutions and global development agencies, so that small-scale farmers, still responsible for most food consumed throughout the world, set agricultural policy. Three interrelated issues need to be tackled: land, markets and farming itself.
Current high world food prices serve as a reminder of the vulnerability of large parts of sub-Saharan Africa and South Asia to hunger and undernutrition. Good nutrition status for children and adolescent girls is fundamental to attaining many of the Millennium Development Goals. Despite this, donors and governments underinvest in interventions to improve nutrition. Underinvestment is due to a lack of incentives for donors; few take a strategic approach to investments that have the potential to improve nutrition and they have little idea whether current investments are making a difference. Furthermore, their ‘critical friends’ – research institutes and non-governmental organisations – lack the leadership to engage with donors strategically on this issue. The authors suggest that this desperate cycle can only be broken by a new alliance between donors, governments and critical friends. This will require new leaders to come forward and develop politically aware strategies that raise public consciousness and put human and financial resources, both public and private, to effective use.
This document is the second of a series addressing issues surrounding poverty and poverty reduction. It explains perceptions of poverty of the poor, well off and development practitioners to give a more complete picture of poverty. The briefing emphasises the need for poor people’s involvement in defining and exploring multiple dimensions of poverty. This points out the drawbacks of relying on understanding and interpretations of researchers and development practitioners. Providing examples from previous studies in Tanzania, Ghana, Bangladesh, India and Pakistan, the document admits that understanding of poverty varied greatly. Therefore the process of arriving at a shared understanding of poverty can be challenging but important.
Rapid urbanisation is a fact of life even in the least developed countries where the lion’s share of the population presently lives in rural areas and will continue to do so for decades to come. This paper examines the causes, consequences and policy implications of ongoing urbanisation in Africa’s less-developed countries (LDCs). The authors find that the employment opportunities in both the rural or urban sectors are not growing adequately. The emerging trends and patterns of urbanisation in the African LDCs are analysed, with a strong emphasis on rural-urban migration and the informal sectors. The paper argues that it is necessary to reverse the trends in aid and provide a much larger share of aid for productive sector development, including the development of rural and urban areas. Also the development of agricultural and non-agricultural sectors is needed, in line with the perspective of the dual-dual model. Although urban centres mostly host non-agricultural industries, sustainable urbanisation also strongly depends on what happens in the agricultural sectors. Productive employment opportunities in rural areas are important in order to combat an unsustainable migration from rural areas to urban centres, and productive employment opportunities in urban centres are essential to absorb the rapidly increasing labour force in the non-agricultural sector. Authors recommend building up productive capacities to create adequate employment and incomes for the rapidly growing population, particularly in the urban areas.
7. Equitable health services
This paper set out to evaluate birth preparedness and complication readiness among antenatal care clients at Kenyatta National Hospital, Nairobi, Kenya. A total of 394 women attending antenatal care were systematically sampled to select every third interviewee for the study. The paper found that over 60% of the respondents were counselled by health workers on various elements of birth preparedness and many were aware of their expected date of delivery, had set aside funds for transport to hospital or for emergencies and knew at least one danger sign in pregnancy. Level of education positively influenced birth preparedness. However, education and counselling on different aspects of birth preparedness was not provided to all clients, especially about danger signs in pregnancy, birth preparedness and plans for emergencies.
This study’s main objective was to determine the length of delays from onset of symptoms to initiation of treatment of pulmonary tuberculosis (PTB). A total of 230 patients aged between 12 and 80 years were included in the study. A cough was the commonest symptom, reported by 99% of the patients, followed by chest pain (80%). Factors like marital status, being knowledgeable about TB, distance to the clinic and where they sought help first had significant effect on how long it took a patient to seek treatment. TB control programmes in this region must emphasise patient education regarding symptoms of tuberculosis and timely health-seeking behaviour.
This preliminary report from Malawi describes a process of developing standards for maternity care together with a multidisciplinary team of health professionals.Conventionally standards for maternity care are developed by a panel of experts (usually obstetricians) and then implemented by a multidisciplinary team. The present study concerns the feasibility of involving health professionals of all grades in the establishment standards for obstructed labour in Malawi. Standards for obstructed labour were developed by a multidisciplinary team involving all cadres of health professionals working in maternity units, as well as hospital managers and policy makers, using evidence from Malawi national guidelines, World Health Organisation manuals and peer-reviewed journals. The standards addressed different aspects of the management of obstructed labour, namely early recognition of prolonged labour by labouring women and traditional birth attendants, early arrival of women to health facilities during labour, proper use of partograph by healthcare providers, proper management of prolonged labour, proper management of obstructed labour, appropriate management of uterine rupture and early delivery of the baby.
The study aimed to evaluate health facility and health worker readiness to deliver new artemetherlumefantrine (AL) treatment policy for uncomplicated malaria in Kenya, using a cross-sectional survey at health facilities in four sentinel districts in Kenya. All government facilities in study districts and all health workers performing outpatient consultations were involved in the study. The availability of any tablets of AL , sulfadoxine-pyrimethamine and amodiaquine was nearly universal on the survey day. However, only 61% of facilities stocked all four weight-specific packs of AL. In the past six months, 67% of facilities had stock-out of at least one AL tablet pack and 15% were out of stock for all four packs at the same time. Duration of stock-out was substantial for all AL packs (median range: 27-39% of time). During the same period, the stock-outs of sulfadoxine-pyrimethamine and amodiaquine were rare. Only 19% of facilities had all AL wall charts displayed, AL in-service training was provided to 47% of health workers and 59% had access to the new guidelines. Health facility and health worker readiness to implement AL policy is not yet optimal. Continuous supply of all four AL pack sizes and removal of not-recommended antimalarials is needed. Further coordinated efforts through the routine programmatic activities are necessary to improve delivery of AL at the point of care.
This paper identifies priorities for disease control as an input into the Copenhagen Consensus effort for 2008 (CC08). The analysis builds on the results of the Disease Control Priorities Project (DCPP). The DCPP engaged over 350 authors and among its outputs were estimates of the cost-effectiveness of 315 interventions. These estimates vary a good deal in their thoroughness and in the extent to which they provide region-specific estimates of both cost and effectiveness. Taken as a whole, however, they represent a comprehensive canvas of disease control opportunities. Some interventions are clearly low priority. Others are attractive and worth doing but either address only a small proportion of disease burden or are simply not quite as attractive as a few key interventions. This paper identifies seven priority interventions in terms of their cost-effectiveness, the size of the disease burden they address, and other criteria.
TB control is hampered by the dual HIV epidemic, and is one of the main reasons for the rapid increase in TB in South Africa, compounded by escalating rates of multidrug resistance (MDR) and the emergence of extensively drug-resistant TB (XDR-TB) in all nine provinces. Rapid diagnosis of drug-resistant TB has been identified as one of the key efforts to find a solution to the control of MDR-TB. A demonstration study under field conditions involving 20,000 TB patients at risk of MDR-TB was conducted in four provinces in South Africa, evaluating the effectiveness of a new molecular test for rapid diagnosis of MDR-TB. Outcomes of this study showed that the test has the potential to revolutionise the control of MDR-TB and its use in TB control programmes has been endorsed by the World Health Organisation. The study showed that the test is highly effective in diagnosing MDR-TB and can be used in laboratory settings in developing countries. Although specialised laboratory facilities and specially trained personnel are required, the test is easy to perform in the laboratory and results are accurate and reproducible. This is very likely one of few instances that global policy for poverty-related disease is driven by evidence generated by scientists and institutions from high-burden countries, such as South Africa, with full credit for the results. The test will be rolled out to all provinces in South Africa, following the acceptance of a new diagnostic algorithm by the National TB Control Programme.
8. Human Resources
In most low-income countries, there is no tradition of labour market regulation, and the professions have little capacity to regulate members' provision of health services, which tends to be weak. The paper looks at the impact of professional monopolies on the performance of health services delivery systems, e.g. equity of access, effectiveness of services, efficiency in the use of scarce resources, responsiveness to users' needs, including protection against the financial impact of utilising health services. It identifies issues which policy-makers face in relation to opening the health labour market while guaranteeing the safety and security of services provided by professionals. A "social contract", granting privileges of practice in exchange of a commitment to actively maintain and enhance the quality of their services, may be a viable course of action. This would require that the actors in the policy process collaborate in strengthening the capacity of regulatory agencies to perform their role.
Drawing from the fields of nursing, healthcare ethics, health systems management, and ecological restoration, the authors of this paper outline the role of social capital for organisational integrity, healthy workplace cultures, sustainable resource management, improved nurse retention, effective knowledge translation and safer patient care. Nursing leaders can use ecological thinking to build the vital resource of social capital by taking concrete steps to commit the necessary human and material resources to: forge relations to foster bonding, bridging and linking social capital; build solidarity and trust; foster collective action and cooperation; strengthen communication and knowledge exchange; and create capacity for social cohesion and inclusion.
Core competencies have been used to redefine curricula across the major health professions in recent decades. In 2006, the Association of Schools of Public Health identified core competencies for the Master of Public Health degree in graduate schools and programmes of public health. The authors provide an overview of the model development process and a listing of twelve core domains and 119 competencies that can serve as a resource for faculty and students for enhancing the quality and accountability of graduate public health education and training. The primary vision for the initiative is the graduation of professionals who are more fully prepared for the many challenges and opportunities in public health in the forthcoming decade.
Two crises dominate the health sectors of sub-Saharan African countries: those of human resources and of HIV. Nevertheless, there is considerable variation in the extent to which these two phenomena affect sub-Saharan countries, with a few facing extreme levels of both: Lesotho, Zimbabwe, Zambia, Mozambique, the Central African Republic and Malawi. This paper reviews the continent-wide situation with respect to this double burden before considering the case of Malawi in more detail. In Malawi, there has been significant concurrent investment in both an Emergency Human Resource Programme and an antiretroviral therapy programme which was treating 60,000 people by the end of 2006. Both synergy and conflict have arisen as the two programmes have been implemented. These highlight important issues for programme planners and managers, particularly that planning for the scale-up of antiretroviral therapy while simultaneously strengthening health systems and human resources requires prioritisation of support and time, and not just resources.
This paper discusses the present and future role of the health professions in health services delivery systems in low-income countries. Unlike richer countries, most low-income countries do not have a tradition of labour market regulation and the capacity of the professions themselves to regulate the provision of health services by their members tends to be weak. The paper looks at the impact of professional monopolies on the performance of health services delivery systems, e.g. equity of access, effectiveness of services, efficiency in the use of scarce resources and responsiveness to users' needs, including protection against the financial impact of utilising health services. It identifies issues which policy-makers face in relation to opening the health labour market while guaranteeing the safety and security of services provided by professionals. A ‘social contract’ - granting privileges of practice in exchange of a commitment to actively maintain and enhance the quality of their services - may be a viable course of action. This would require that the actors in the policy process collaborate in strengthening the capacity of regulatory agencies to perform their roles.
This study aimed to highlight the experience and findings of an attempt at establishing the optimal staffing levels for a tertiary health institution using the Workload Indicators of Staffing Need (WISN) method popularised by the World Health Organisation (WHO), Geneva, Switzerland. The descriptive study captures the activities of a taskforce appointed to establish optimal staffing levels. The cadres of workers, working schedules, main activities, time taken to accomplish the activities, available working hours, category and individual allowances, annual workloads from the previous year's statistics and optimal departmental establishment of workers were examined. There was initial resentment to the exercise because of the notion that it was aimed at retrenching workers. The team was given autonomy by the hospital management to objectively establish the optimal staffing levels. Very few departments were optimally established with most either understaffed or overstaffed. There were intradepartmental discrepancies in optimal levels of cadres even though many of them had the right number of total workforce. The WISN method is a very objective way of establishing staffing levels but requires a dedicated team with adequate expertise to make the raw data meaningful for calculations.
9. Public-Private Mix
West African people should establish a medical anti-counterfeiting task force to promote local herbal medicines by protecting indigenous knowledge and genetic property. This is according to the communiqué from a workshop held in Accra, Ghana from 21-23 July 2008. A survey conducted by WHO between January 1999 and October 2000 found 60% of counterfeiting incidents occurred in developing countries and 40% in industrialised nations. To protect the local medical industries, the task force will prepare a mechanism for reporting counterfeit issues, including its harmful effect on local economy and health and launch awareness creation programmes as well as advising governments and local companies on ways to increase the use of security features on their products including medicines, cosmetics and medical devices. According to President Kufuor, this protection of intellectual property rights for local medical industries will sustain socioeconomic development that depends on investment and the growth of local industries, entrepreneurs and innovators who are willing to invest the capital needed to create brands and copyrights and to deploy money into research and development necessary to produce products which are accorded IP rights.
Data from every part of the world show that those that are least well off have shorter life expectancies and heavier burdens of disease than those that are relatively wealthy. Subsequently, public–private partnerships (PPPs) have gained growing popularity as mechanisms for increasing access to essential drugs. This series of papers examines the characteristics of PPPs that aim to improve the health of the world’s poorest people. The authors contribute to the debate about the future role of PPPs and provide pointers to key areas for urgent attention to sustain and increase the momentum to reach the goals towards which PPPs are striving. Issues highlighted include the roles of different actors in partnerships involving public sector and philanthropic donors, the private sector, nongovernmental organizations, communities and researchers in developed and developing countries.
India's government could become the country's only purchaser of patented drugs and medical devices, under new proposals currently being discussed by ministers. While other nations operate central medicines buying for their public health care systems, this would be the first instance of a government also becoming the sole supplier for private health care providers, and could set a precedent for African countries.
Data from every part of the world shows that those who are least well off have shorter life expectancies and heavier burdens of disease than those who are relatively wealthy. Subsequently, public-private partnerships (PPPs) have gained growing popularity as mechanisms for increasing access to essential drugs. This series of chapters examines the characteristics of PPPs that aim to improve the health of the world’s poorest people. The authors contribute to the debate about the future role of PPPs and provide pointers to key areas for urgent attention to sustain and increase the momentum to reach the goals towards which PPPs are striving. Issues highlighted include the roles of different actors in partnerships involving public sector and philanthropic donors, the private sector, nongovernmental organisations, communities and researchers in developed and developing countries. The picture that emerges is multifaceted and complex. The PPP approach has evidently focused attention on some neglected areas and has galvanised action that is bringing new resources and innovative solutions to address some health problems. But many challenges remain if their promise is to be fulfilled, including greater and more sustainable financing over the longer term and better mechanisms for coordination. The authors highlight that the ethical imperative of reducing health inequities - closing the gap between the health of the poorest and those who are better off - demands the utmost collective effort.
10. Resource allocation and health financing
More international aid has been dedicated to fighting HIV and AIDS than any other disease, but what impact have all those donor dollars had in countries where HIV and AIDS funding often exceeds total domestic health budgets? The three largest HIV and AIDS donors - the Global Fund to Fight AIDS, Tuberculosis and Malaria, the US President's Emergency Plan for AIDS Relief (PEPFAR) and the World Bank's Multi-Country AIDS Programme (MAP) - have spent US$20 billion on combating AIDS since 2000. This report, launched at the International AIDS Conference in Mexico City, suggests that AIDS donors may actually have weakened the health systems necessary for an effective AIDS response. Noting that ‘the future of the global HIV/AIDS response cannot be considered independently from that of national health systems,’ the study examined interactions between the three donors and health systems in three countries where they work: Mozambique, Uganda and Zambia. Focusing on three components of those health systems - health information systems, supply chains for essential drugs, and human resources - the researchers found that donors had developed AIDS-specific processes, often creating a drain on resources essential to the country's broader health system.
In September 2008, ministers from over 100 countries, heads of bilateral and multilateral development agencies, donor organisations, and civil society organisations from around the world will gather in Accra for the Third High-level Forum on Aid Effectiveness (2-4 September). Their common objective is to help developing countries and marginalised people in their fight against poverty by making aid more transparent, accountable and results-oriented. The Third High Level Forum on Aid Effectiveness (Third HLF) will review progress in improving aid effectiveness broaden the dialogue to newer actors and chart a course for continuing international action on aid effectiveness.
A robust public financial management (PFM) system is vital to a country’s development efforts and to the effectiveness of the aid funds that support those efforts. Three years ago, the Paris Declaration on Aid Effectiveness gave new prominence to this idea, as partner countries committed to strengthen their PFM systems and donors committed to use those systems. Now, as the development community prepares for the Third High Level Forum on Aid Effectiveness, this report takes stock of these achievements. The report finds that there has been progress: many countries and donors have taken positive action toward strengthening and using country PFM systems, and the Public. Expenditure and Financial Accountability (PEFA) partnership has developed a performance measurement framework that can help countries determine where they need to concentrate their efforts. At the same time, the aggregate numbers on donors’ use of country systems have not changed much; it is clear that there is still much work to do. The report argues that many of the conditions on which that work must build are now in place, so there is good reason to expect that the Paris Declaration targets for 2010 can be achieved. The report makes important recommendations for this work: partner countries need to take an enhanced role, donors need to better equip themselves to carry out their commitments, external accountability bodies (such as parliaments and civil society organisations) need to increase their demand for implementation of the Paris Declaration, and planning, communication, dissemination and use of lessons learned are crucial.
There are over a million older persons in Uganda, many of whom lack food, money, clean water and medical support and have lost their children to war and AIDS. This paper, based on a survey of older persons and a follow-up conference, which analysed the results, collates the major issues facing many older persons in Uganda, the policy response so far and outlines priorities for action in the future. Despite the fact that in the Ministry of Gender, Labour and Social Development, there is a Minister of State for Elderly and Disability, there is in 2008 still no policy for older persons. Lack of a formal policy on ageing is harming the elderly in Uganda. The government needs to introduce specific programmes to support older persons who care for their orphaned grandchildren, start HIV and AIDS education and testing programmes for older persons, initiate geriatric medicine at hospitals and health centres and establish a National Council on Ageing.
A new study has shown a link between IMF loans to developing countries and increased levels of tuberculosis in the same countries. Researchers claimed a direct relationship could be seen - the start of the increases matched the starting point of IMF programmes, and continued rising as the programme continued. This meant at least a 16.6% increase in deaths across the 21 researched countries, they said. Without the IMF loans, rates would have fallen by up to 10%.
11. Equity and HIV/AIDS
A key feature of South Africa’s HIV epidemic, where 5.7 million people are positive, is that among the 15-24 year olds infected, women and girls account for more than 90% of new infections. This needs a special focus on this group when designing prevention programmes, says UNAIDS. The HIV and AIDS epidemic in South Africa is stabilising, according to a report released last week by the Joint United Nations’ Programme on HIV and AIDS. This means that there has not been a recognisable increase in the rate of new infections over the last few years. Instead, the infection rate has remained relatively constant. This, however, does not mean that the epidemic is declining, as the country still holds the unenviable world number one position in the stakes of the total number of people living with HIV. The fact that women and girls continue to be disproportionately infected points to a failure of HIV programmes in addressing the issues that place females at risk of HIV infection, says the United Nations’ Special Envoy on AIDS in Africa, Elisabeth Mataka.
Over 22,000 of the world’s key HIV and AIDS scientists, academics and activists attended 17th international AIDS conference in Mexico City. The HIV/AIDS sector has been under attack recently by some health practitioners who argue that too much money is being spent on HIV and AIDS to the detriment of other diseases. However, Craig McClure, the executive director of International AIDS Society (IAS) says it is unfortunate that the criticism that HIV is distorting health systems comes at a time ‘when success is finally in our hands’. ‘There is no doubt that in order for us to achieve the 2010 Universal Access targets, health systems must be further strengthened,’ said Cahn. ‘This will require an increase in resources, including additional resources for commodities like drugs and diagnostic tools, basic health care infrastructure and the training and retaining of the health care workforce. With the life-long interventions brought by antiretroviral therapy, the success of HIV and AIDS programmes around the world is dependent on health systems strengthening.’
This study examines clinical waste disposal and handling in the context of a community home-based care (CHBC) programme in Kanye, southern Botswana. This qualitative study involved 10 focus group discussions with a total of 82 AIDS primary caregivers in Kanye, one-to-one interviews with the five nurses supervising the programme, and participant observation. Numerous aspects of clinical or healthcare waste management were found to be hazardous and challenging to the home-based caregivers in the Kanye CHBC programme, namely: lack of any clear policies for clinical waste management; unhygienic waste handling and disposal by home-based caregivers, including burning and burying healthcare waste, and the absence of pre-treatment methods; inadequate transportation facilities to ferry the waste to clinics and then to appropriate disposal sites; stigma and discrimination associated with the physical removal of clinical waste from homes or clinics; poor storage of the healthcare waste at clinics; lack of incinerators for burning clinical waste; and a high risk of contagion to individuals and the environment at all stages of managing the clinical waste.
Correct and consistent condom usage remains a pivotal strategy in reaching the target set by the South African government to reduce new HIV infections by 50% in the next 5 years. Studies have found that there has been an increase in condom usage by some categories of the population, but usage has not yet reached the desired levels in order to meet the target. This article reports on the findings of a study on condom usage in eight communities in the North West Province, which was part of a wider HIV and AIDS programme evaluation commissioned by the North West Provincial Department of Health. The main aim was to assess accessibility to condoms, and knowledge, attitudes and practices around condom use by four sampled communities in the North West Province. Eight focus group discussions were held and 50 households were interviewed. The study found positive results regarding accessibility and awareness of condoms. However, this often did not lead to the desired behavioural change of using condoms in risky sexual interactions. The majority of respondents still resisted condom usage, used condoms inconsistently, or were not in a position to negotiate protected sexual intercourse. The main reasons reported for this were: reduced pleasure, perceived and real physical side-effects, myths, lack of information, status, financial reasons, distrust in the efficacy of condoms, family planning, cultural reasons, gender-related reasons and trust. Many of the barriers to consistent condom use cannot be overcome by strategies that target the individual. Interventions need to address underlying developmental factors such as the non-biological factors that increase the susceptibility of women to HIV infection. As this falls outside of the scope of the mandate of the Department of Health, various partnerships with other key role players need to be established and/or strengthened, such as with local government, non-governmental organisations and faith-based organisations.
A comprehensive care and treatment program requires a well functioning laboratory services. This study assessed satisfaction of medical personnel to the laboratory services to guide process of quality improvement of the services. A cross-sectional survey in 24 randomly selected health facilities in Mainland Tanzania was conducted to assess the satisfaction of the medical personnel with the laboratory services. About one quarter of medical personnel in sending or receiving laboratories were dissatisfied with the services. Comparing the personnel in public and private, the personnel in public laboratories were 4 times more dissatisfied with the timely test and correct results; and 5 times more dissatisfied with clear and complete test results.
HIV-infected women need support to deal with their diagnosis as well as with the stigma attached to HIV. As part of their practical training, Master's-level psychology students negotiated with the staff of four clinics in townships in Tshwane, South Africa, to establish support groups for HIV+ women and offered to assist them in facilitating the groups. This study aimed to understand why the implementation of groups was successful in one clinic and not other clinics. The student reports on their experiences, and interactions with clinic staff and clients were used as a source of data. Using qualitative data analysis, different dynamics and factors that could affect project implementation were identified in each clinic. Socio-ecological and systems theories were used to understand implementation processes and obstacles in implementation. Valuable lessons were learnt, resulting in the development of guiding principles for the implementation of support groups in community settings.
The rate of new HIV infections, which has fuelled the global HIV/AIDS epidemic since the 1980s, has peaked throughout the world and is now declining. But population growth and the life-prolonging effects of antiretroviral (ARV) treatment mean that the total global number of HIV-infected people is likely to remain about the same for another two decades and will continue to increase in sub-Saharan Africa. Based on these findings the authors say it is time for the international community and governments to rethink their prioritisation of AIDS over other infectious diseases.
This study assessed the health-related quality of life and HIV symptoms of a sample of people living with HIV (PLHIV) in South Africa. The sample included 607 PLHIVs from all districts of the Eastern Cape Province, recruited either through a health facility, from the community through key informants, or through support groups. The findings indicate a low degree of overall quality of life, with spirituality, environment, psychological health and level of independence as predictors for overall quality of life. Among medical variables and HIV symptoms, CD4 cell count and having fewer HIV symptoms (but not an AIDS diagnosis) were identified as predictors for overall quality of life. Among socio-economic variables, having sufficient food and a higher educational level were identified as predictors. The results highlight the need for better access to psychosocial support and medical services for PLHIV in South Africa, as well as the need to consider a patient's general health perceptions during the course of ART.
This publication defines the essential interventions the health sector should deliver and provides key references as well as links to web-based resources. The document provides WHO’s best attempt to assemble and package normative advice for the health sector concerning the essential response to HIV/AIDS. We hope it will prove useful for all those who work in the health sector, whatever their capacity, as they confront the realities of HIV/AIDS throughout the world.
This paper examines the history of HIV/AIDS in Kenya since it was first diagnosed in the country. The introduction of highly active antiretroviral therapy (HAART) has dramatically improved the prognosis for individual patients with AIDS, but education and changing attitudes towards condoms have led to a progressive fall in incidence, so that the worst of the epidemic may now be over. Limited personal experience suggests that steroids may also have a role in salvaging critically ill AIDS patients, who need to be treated as emergencies. With an educated public and attention to alternative routes of infection such as blood transfusion, the epidemic should be increasingly contained during the next 25 years, and may even fizzle out.
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12. Governance and participation in health
Improving quality of primary care is a key focus of international health policy. Two methods of improving the quality of interpersonal care in primary care have been proposed. One involves the feedback of patient assessments of interpersonal care to physicians, and the other involves brief training and education programmes. This study therefore reviewed the efficacy of (i) feedback of real patient assessments of interpersonal care skills, (ii) brief training focused on the improvement of interpersonal care and (iii) interventions combining both (i) and (ii). Nine studies were included (two patient based feedback studies and seven brief training studies). Of the two feedback studies, one reported a significant positive effect. The authors conclude that there is limited evidence concerning the effects of patient based feedback. There is reasonable evidence that brief training as currently delivered is not effective, although the evidence is not definitive, due to the small number of trials and the variation in the training methods and goals.
This report covers the Civicus Participatory Governance Programme: How can we build political for participatory governance, 17-18 June 2008. Although participatory governance offers important concrete benefits for citizens and state actors alike, there is often initial resistance from political actors and government offiicals who are unfamiliar with such approaches. This small working group session involved three case studies which describe and analyse Civil Society Organisation approaches to building political will for participatory governance.
This paper examines the cultural and structural difficulties surrounding effective prevention of mother-to-child HIV transmission (PMTCT) in rural Lesotho. It argues for three strategies to improve PMTCT interventions: community-based research and outreach, addressing cultural and structural dynamics, and working with the relevant social groups that impact on HIV prevention. These conclusions are based on interviews and participant observation conducted within the rural Mokhotlong district and capital city of Maseru, involving women and men of reproductive age, grandmothers serving as primary caretakers, HIV and AIDS programme staff and medical professionals. Qualitative analysis focused on rural women's socio-medical experience with the four measures of PMTCT (educational outreach, voluntary counselling and testing, antiretroviral interventions and safe infant feeding). Based on these results, the paper concludes that intervention models must move beyond a myopic biomedical ‘best-practices' approach to address the social groups and contextual determinants impacting on vertical HIV transmission. Given the complexities of effective PMTCT, our results show that it is necessary to consider the biomedical system, women and children, and the community as valuable partners in achieving positive health outcomes.
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. A sequence of possible steps and tools, including do’s and don’ts, are provided to help trigger CLTS in a community. They include pre-triggering, selecting a community, introduction and building rapport, triggering participatory sanitation, profile analysis, ignition moment, post-triggering action, planning by the community, follow up, scaling up and going beyond CLTS. Users are encouraged to use and modify the processes outlined in this handbook as they see fit for their given context.
This report aims to shed light on the way innovative solutions have arisen to address local sustainable development challenges, examining the determinants of success and the scope for replication. The report focuses on the African experience. The volume is composed of ten case studies, selected for their truly innovative nature, effective implementation, significant outputs and generation of real social welfare improvements, grouped under five headings: enhancement of agriculture and fisheries, protection of ecosystems, water management, health improvement and sustainable tourism. Practical conclusions drawn from the case studies include: sustainable projects need to link environmental goals to income generation, draw upon local knowledge and ideas, ensure effective buy-in from stakeholders through local community involvement in project design and implementation, and employ financially self-sustaining business models external forces which impact on a project and affect conditions for success, including international markets and national legislation. In some cases though, local success can provide arguments for more accommodating national policies to facilitate replication and scaling up simplicity in project design. Committed seed capital and integration of local traditions and cultural heritage appear to be important success factors for innovative local initiatives.
In many parts of Asia and sub-Saharan Africa there is a growing gap between official accounts of how health systems operate and realities on the ground. Researchers in this study looked at how to gain access to competent health care in environments where there are growing but unorganised markets in goods and services, blurred boundaries between the public and private health care sectors, and a lack of state regulation. The researchers used the frame of the ‘social contract’ (an implicit agreement among people that results in the organisation of society) and focused on the problem of information asymmetry (inequalities in access to information) and associated power relationships, in particular those between patient and health care provider. Their paper highlights the importance of trust to relationships at all levels of the health system. Findings show that different ways of generating trust in goods and services, and new forms of regulation have emerged. The researchers call for greater understanding of the institutional context in which health systems operate in developing countries. They also stress the need to avoid dictating policy according to the experiences of developed countries. Instead, future debates will need to focus on how governments can create regulatory partnerships and enable improved access to information, building on the new social contracts that are already emerging.
13. Monitoring equity and research policy
Trial participants from limited-resource settings often are given very little or nothing in terms of compensation for time, inconvenience and risks, as compared to their counterparts from developed countries. The reason most often cited by researchers, ethics committees and sponsors is the avoidance of undue inducements. This paper discusses the inherent conflict that may arise in trying to avoid undue inducement and in trying to minimise injustice in international research. It argues that research participants from both industrialised nations and limited-resource countries should be compensated equally since they suffer the same burdens and equally contribute towards the study by contributing the same product data.
Over the past ten years calls to strengthen health systems research capacities in low- and middle-income countries have increased. One mechanism for capacity development is the partnering of northern and southern institutions; however, detailed case-studies of north-south partnerships, at least in the domain of health systems research, remain limited. This study aims to evaluate the partnerships developed between the Health Economics and Financing Programme of the London School of Hygiene & Tropical Medicine and three research partners in South Africa and Thailand to strengthen health economics-related research capacity. Five years of formal partnership resulted in substantial strengthening of individual research skills and moderate institutionalised strengthening in southern partner institutions. Activities included joint proposals, research and articles, staff exchange and post-graduate training. In South Africa, local post-graduate teaching programs were strengthened, regular staff visits/exchanges initiated and maintained and funding secured for several large-scale, multi-partner projects. These activities could not have been achieved without good personal relationships between members of the partner institutions, built on trust developed over twenty years. In South Africa, a critical factor was the joint appointment of a London staff member on long-term secondment to one of the partner institutions. As partnerships mature the needs of partners change and new challenges emerge. Partners' differing research priorities need to be balanced and equitable funding mechanisms developed recognising the needs and constraints faced by both southern and northern partners. Institutionalising partnerships (through long-term development of trust, engagement of a broad range of staff in joint activities and joint-appointment of staff), and developing responsive mechanisms for governing these partnerships (through regular joint negotiation of research priorities and funding issues), can address these challenges in mutually acceptable ways. Most importantly, this study has shown that it is possible for long-term north-south partnership commitments to yield fruit and to strengthen the capacities of public health research and training institutions in less developed countries.
The advent of HIV pre-exposure prophylaxis (PrEP) as a HIV-prevention strategy has received optimistic support among HIV researchers. However, discourse on PrEP trials has tended to be dominated by the disputes arising between some activist groups and researchers about the research methodologies. Instead, this paper discusses other issues oftentimes neglected in discussions relating to PrEP trials. Specifically, it focuses on the possible ethical implications and the potential impact of sub-Saharan Africa's socio-economic conditions on the promised benefits of PrEP trials for the region and the continent. We argue that the concept of PrEP as a affordable and practical HIV-prevention intervention presents challenges and questions that urgently need addressing as researchers await results from several ongoing trials. If research is undertaken with no plans on how the results of specific trials can render actual HIV-prevention-benefits — especially for the world's poor — then such endeavours risk being merely information-acquiring ventures.
Maternal mortality remains poorly researched in Africa, and is likely to worsen dramatically as a consequence of HIV/AIDS. The 2001 census of South Africa included a question on deaths in the previous 12 months, and two questions on external causes and maternal mortality, defined as "pregnancy-related deaths". A microdata sample from the census permits researchers to assess levels and differentials in maternal mortality, in a country severely affected by high death rates from HIV/AIDS and from external causes. After correcting for several minor biases, our estimate of the Maternal Mortality Ratio (MMR) in 2001 was 542 per 100,000 live births. This level is much higher than previous estimates dating from pre-HIV/AIDS times. This high level occurred despite a relatively low proportion of maternal deaths (6.4%) among deaths of women aged 15-49 years, and was due to the astonishingly high level of adult mortality, some 4.7 times higher than expected from mortality below age 15 or above age 50. The main reasons for these excessive levels were HIV and AIDS and external causes of deaths. The differentials in MMR were considerable: 1 to 9.2 for population groups (race), 1 to 3.2 for provinces, and 1 to 2.4 for levels of education. Relationship with income and wealth were complex, with highest values for middle income and middle wealth index. Demographic census microdata offer the opportunity to conduct an epidemiologic analysis of maternal mortality. Indirect causes of maternal deaths appear much more important than direct obstetric causes. The MMR appears no longer to be a reliable measure of the quality of obstetric care or a measure of safe motherhood.
Current literature suggests that therapeutic misconception – a belief by participants in a clinical trial that they are in fact simply being given clinical care – is common, especially among illiterate populations in developing countries. In this study, most participated in research for the sake of obtaining better quality treatment made available through the clinical trials as ancillary care. Their consent to participate was not due to a belief that the actual procedures of the trial would directly benefit their health but due to government hospitals being crowded and commonly lacking drugs. In this environment, people make rational decisions to participate in research. This paper questions whether the term ‘therapeutic misconception' accurately describes participants' motivation under conditions of limited resources and discusses the issue of undue inducement in clinical trials.
Participants' refusal to take part in research is an unpleasant experience that investigators face. This paper highlights some of the reasons why people from resource-poor settings refuse to take part in health research, highlighting standards that investigators can adopt to avoid unnecessary refusals and at the same time ensure that individuals have the right to participate and freedom to refuse. The researchers conducted focus group discussions with people who had refused to take part in a number of biomedical research studies but agreed to be interviewed in this study. They found nine key factors that influence people to refuse to participate in biomedical research: failure to follow traditional customs, lack of study benefits, superstition, poor informed-consent procedures, ignorance of health research, fear of strangers, lack of cultural sensitivity, poor timing and previous bad research experiences. They recommend that researchers must embark on community engagement before implementing their studies.
This study was aimed at researching the reasons why mothers enrol their children in malaria clinical research and how family members or relatives are involved in the decision-making process. Issues related to informed consent were also a particular focus of this study. A total of 81 participants took part in eight focus group discussions, all of whom were mothers whose children had participated or were participating in Intermittent Prevention Therapy post-discharge (IPTpd) malaria research. Most of the participants reported that they chose to participate in the IPTpd research as a way of accessing better quality medical care and to benefit from the material and monetary incentives that were being given to participants for their participation. There was also a sense of trust in health workers who asked the potential participants to join the research. Most participants decide to take part in malaria research because of better medical treatment. Partners and relatives played a very small role in their decision-making process.
There is an increase in the amount of genetics research being conducted in both developed and limited-resource countries. Most of this research is sponsored by developed countries. There are concerns in limited-resource countries on how the benefits from this research are currently being shared or will be shared in the future. There is need for caution to ensure that populations from limited-resource countries are not exploited by being used as subjects in genetics research that is meant to benefit populations from developed countries. This paper addresses the issue of fairness in benefits sharing and argues for justice in the sharing of both burdens and benefits of genetics research. The paper responds to some of the issues and arguments in recent literature on the meaning and limits of the concept of benefit-sharing in human genetics research.
14. Useful Resources
The demographic divide - inequality in the population and health profiles of rich and poor countries - is widening. Two sharply different patterns of population growth are evident: little growth or even decline in most wealthy countries and continued rapid population growth in the world’s poorest countries. The 2008 World Population Data Sheet and its summary report offer detailed information about country, regional and global population patterns. It provides up-to-date demographic, health, and environment data for 209 countries and 25 regions of the world. It points up stark contrasts between developed and developing countries and predicts that the world population will soon have an urban majority. In 2008, for the first time, half of the world’s population will live in urban areas. Despite some improvement, maternal mortality continues to be very high in developing countries. In the least-developed countries, 35% of the population consumes fewer than the minimum calories required to lead a healthy active life. That figure rises above 60% in several sub-Saharan countries.
HIFA2015 is a campaign and a knowledge network, building the HIFA2015 Knowledge Base, a picture of information needs and how to meet them. HIFA2015 involves more than 1,500 people from 110 countries worldwide. Members include health workers, publishers, librarians, information technologists, researchers, social scientists, journalists, policy-makers and others - all working together towards the HIFA2015 goal: by 2015, every person worldwide will have access to an informed healthcare provider. Membership is free and open to all.
As part of the ‘This is Public Health’campaign, ASPH has developed the This is Public Health toolkit which will serve as a resource for anyone who is interested in educating others about public health issues or the field of public health. The materials in the toolkit are suggestions or templates, which can either be used as is, or tailored to suit your specific audiences. The toolkit also includes links for other sources that can increase knowledge of public health both inside and outside the classroom. Materials will be provided that target a range of individuals, accommodating varying age groups and differing levels of familiarity with the field of public health. Organisations with communication or presentation tools to share with others on this site can email stickers@asph.org and ASPH to upload your suggestions.
Professional writing can be a difficult process for development practioners, especially for those who do not have English as a first language. This module is part of the reporting skills and professional writing handbook comprised of eight easy to follow steps covering the entire writing process aimed at creating an understanding of what professional writing is and how to improve these writing skills.
What are the benefits of disseminating research online? How would you go about it if you do not have your own website? This toolkit addresses these and other questions, providing broad tips and suggestions for communicating academic research using the internet. It draws on best practice for web strategies from the information and commercial worlds. The toolkit identifies and focuses on five key elements of the process, including the Global Development Network (GDN) approach to research communication including GDNet style guides and a downloadable power point presentation about communicating research online. The author stresses that this toolkit does not cover everything needed for a comprehensive research dissemination strategy for institutes. Such a strategy will involve other channels of communication (paper-based outputs, meetings, workshops etc) and will depend on target audiences, institutional set up and finances.
15. Jobs and Announcements
You are invited to submit an abstract for consideration by the Scientific Programme Committee for participation at the 4th SA Aids Conference programme. The conference is scheduled to place at Durban International Convention Centre from 31 March – 3 April 2009. The theme of the conference is “ Scaling up for Success”. Abstracts will be reviewed according to the following tracks: Basic Sciences; Clinical Sciences; Epidemiology, Prevention and Public Health; Social and Economical Sciences, Human rights and Ethics; Best Practices and Programmes; and Community Exchange Encounters. Abstracts can only be submitted electronically through the SA AIDS Conference website. Abstracts submitted to the conference secretariat directly through any other means will not be accepted for review. Please draft your abstract according to the headings listed below in no more than 300 words in total. You may draft your abstract in text format only using a word processing software i.e MS Word and then copy and paste the text in the abstract submission box.Note that no graphic images, tables, graphs or columns should be submitted with your abstract. Abstract submissions close on 31 December 2008
The Botswana Review of Ethics, Law and HIV/AIDS (BRELA) is a journal published by the Botswana Network on Ethics, Law and HIV/AIDS (BONELA) based in Gaborone, Botswana. BRELA is a peer-reviewed journal intended to create a participatory forum for critical and analytical discussion of a broad range of multi-sectoral issues and debates surrounding HIV and AIDS. The journal is looking for submissions from researchers and writers.
CTS Global is comprised of individuals with unique backgrounds and interests. Our team members are located domestically and around the world; profoundly impacting and adding value to every work assignment. The following positions are currently available with CTS Global: Clinical Laboratory Mentor; Infrastructure Projects Advisor; Cooperative Ag. Program Specialist; IT Specialists; Epidemiologist; Laboratory Advisor; Health Information Systems Advisor; Monitoring and Evaluation Advisor; HIV/AIDS Medical Officer; TADR Project Advisor.
Canon Collins Trust currently manages a scholarship programme on behalf of Mrs. Graça Machel. The aim is to provide female students from Lesotho, Malawi, Mozambique, Swaziland, South Africa and Zambia with scholarships that will equip them to take up leadership roles for the benefit of their community, nation and region. One of the key concerns of Mrs Machel is giving a voice to rural women and the scholarship is therefore aimed at empowering rural women. The Graça Machel scholarship is for women who have experienced significant struggle in their life and who have sought to overcome those barriers, be they related to gender, disability, poverty, age or racial discrimination. Applicants will be expected to demonstrate clearly how their application fits within this vision of empowerment. All scholarships are for postgraduate study, for two years if based in South Africa. The scholarship includes payment of a maintenance allowance, travel, health insurance and tuition fees. Scholarships are awarded on a competitive basis to women on the basis of academic/professional merit, financial need, intended academic programme, leadership potential and commitment to work for constructive change in Africa. Applicants must have at least two years relevant work experience. Subject Areas include: Health; Education; Science and Technology; Economics and Finance; and Development. The closing date for applications is 31st August 2008.
The IHHR is planning to host the next UNSW Intensive Course on Health, Development and Human Rights from 8th - 12th December 2008 on the Kensington Campus of the University of New South Wales, Sydney, Australia. New opportunities and risks associated with human development, widening gaps between health needs of particularly vulnerable populations and responses to these needs, and widespread movements of people through labour and forced migration as a consequence of economic pressure, climate change, conflicts and natural disasters, are key issues for the new millennium.
CIVICUS is recruiting for a Participatory Governance Project Coordinator to lead a multi-country project in Africa involving a range of country-level and international partners. The project seeks to enhance the capacity of citizens and their organisations to make use of evidence-based participatory approaches in engaging with governments to promote greater transparency, responsiveness and accountability. Besides contributing to project design and providing technical assistance in participatory governance to country-level partners, the incumbent will be responsible for project administration, including budget and reporting; supporting country-level partners in networking and institutional development, and organising regional and global learning events. Submit a cover letter, a detailed CV and the contact details of 3 referees to humanresources@civicus.org by Monday 15 September 2008.
Transparency International (TI) is a global civil society organisation leading the fight against corruption. Through more than 90 chapters worldwide and an international secretariat in Berlin, Germany, TI raises awareness of the damaging effects of corruption and works with partners in government, business and civil society to develop and implement effective measures to tackle it. Transparency International is looking for a senior research coordinator to manage the research components of a three-year, eight-country programme on ‘Transparency in Service Delivery in Africa’ (TISDA). The programme seeks to improve delivery in basic services in three key sectors (education, health and water) by empowering civil society to advocate for improved transparency and accountability in the management of financial resources in these sectors. Working closely with TI’s Africa and Middle East Department, participating TI national chapters and external (national and international) consultants, the senior research coordinator will be responsible for overseeing the design, implementation and analysis of public sector service delivery surveys on education, health and water in participating African countries (Cameroon, Ghana, Kenya, Nigeria, Senegal, South Africa, Uganda and Zambia).
The London School of Hygiene and Tropical Medicine are holding this event in recognition of the historical importance of the Alma-Ata declaration, and the continuing interest in primary health care from a range of stakeholders. The key objectives of the symposium are to highlight successes of failures of primary health care (PHC) in the last 30 years; discuss how to apply the lessons learned to strengthen health systems for future challenges; look at the threats / challenges to the PHC approach and how to combat them; outline the tensions between disease specific programmes and PHC approaches - how can they be addressed?; identify Alma-Ata values and how they can be translated into programmes; and consider the implications of PHC for decision makers( donors, governments, research funders, academic institutions) in the future.
Health Action International (HAI) Africa and the Southern African Treatment Access Movement (SATAMO), with support from the Open Society Institute’s Public Health Programme, will organise a seminar on access to essential medicines (AEM) in Nairobi in October 2008.
York University (Toronto) working with the Training and Research Support Centre is running an internet-based course, “Civil Society and the State in Africa”, in September 2008 – April 2009. Members of civil society organisations in East and Southern Africa are invited to apply for participation in the course, which is provided free-of-charge. The 12-unit course will take place over 26 weeks, and is designed for civil society practitioners and post-secondary students (see the Lecture Schedule and Topics at the end of this announcement). The course is intended to provide both a firm grounding in current research and debates on civil society interventions around issues of social and economic policy and to provide capacity building in analysis for research on civil society - state interactions in social policy. By the end of the course, students should have a strengthened background in theoretical, strategic and practical issues in and approaches to civil society- state interactions in policy development and implementation, and an improved capacity to locate relevant research sources and support mechanisms for future policy-oriented work. York University will provide formal written acknowledgement of a student’s successful completion of the course once all of the course requirements have been met. Please email your application BEFORE 30 AUGUST 2008 to the following address: rsaunder@yorku.ca and admin@tarsc.org.
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