In the context of Africa’s present health crisis, only people suffering from policy blindness can fail to see that Africa’s survival as a continent depends on going beyond merely declaring emergencies, and actually financing and implementing universal primary health care (PHC).
In September 1978, the International Conference on Primary Health Care was held in Alma-Ata, Kazakhstan, then part of the Union of Socialist Soviet Republics (USSR). Led by the World Health Organisation (WHO), the conference produced the Alma-Ata Declaration, which underlined the need for governments to protect the health of all citizens and emphasised that health for all is both a socio-economic (or development issue), and also a human right. The conference also highlighted the inequalities between developed and developing countries, and between the elite and ordinary people within countries.
One of the most significant outcomes of the conference through the Alma-Ata Declaration identified primary health care as ‘the most efficient and cost effective way to provide health care’. This has been recently reemphasised by the current Director General of the WHO Dr Margaret Chan.
Going by its definition of ‘essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation’ and the principle that ‘[h]ealth services must be shared equally by all people irrespective of their ability to pay and all (and rich or poor, urban or rural) must have access to health services’, it was assumed at the time that with effective implementation PHC would lead to health for all by the magical year 2000.
Based also on the understanding of health agencies, professionals and academic institutions that ‘primary health care needs to be delivered close to the people’ through ‘maximum use of both lay and professional health care practitioners’, experts have distilled down the basic principles of primary health care to several core factors, including: • Public education for the identification, prevention, and control of prevailing health challenges • Education on and provision of proper food supplies and nutrition, including adequate supply of safe water and basic sanitation • Provision of maternal and child care, including sexual and reproductive health education, and family planning • Immunisation and vaccinations against major infectious diseases. • Prevention and control of locally endemic diseases • Appropriate treatment of common diseases using the most up-to-date, cost effective and appropriate technology • Promotion of mental, emotional and spiritual health • Provision of essential drugs and commodities.
It cannot be emphasised enough that these primary health care principles can only be possible through long-term sustainable and combined financing of both health systems, and disease specific interventions. The phantom debate over ‘health systems versus disease specific interventions’ is a false one and a diversion equivalent to asking if food is more important than water to human life. It should be reasonably obvious that health systems without medicines and commodities are as useless as medicines and commodities without health systems. This applies to all health issues, whether malaria, TB or HIV/Aids.
Sustainable and long-term health financing must therefore mean identifying the specific challenges and obstacles to primary health care, and on the basis of costed plans work out clear and timely frameworks for resolving these obstacles. In addition to disease specific and wider health system challenges, this includes focusing on the resolution of key obstacles such as the lack of policies and financing sustainable plans for reproductive and sexual health, and resolving Africa’s critical health workforce shortage.
This editorial comes from the joint EQUINET newsletter issue with Pambazuka for the thirty years of Primary Health Care. The Africa Public Health Alliance & 15% Now Campaign engages African governments, global and African and institutions on implementation of the AU Africa Health Strategy, Health MDGs and fulfilling the AU Abuja pledge to allocate 15% of domestic national resources to health. For further information on the issues raised contact admin@equinetafrica.org
1. Editorial
In 1974, four years before the International Conference on Primary Health Care (PHC) was convened in Alma-Ata, USSR, the Canadian Ministry of National Health and Welfare published the Lalonde Report, named after the incumbent Liberal Party health minister Marc Lalonde.
Taking its cue from Thomas McKeown’s findings on the historical decline of tuberculosis mortality in England and Wales, the Lalonde Report challenged the presumption that improvements in human health by and large flowed from advances in (bio)medical knowledge, feeding through to professional practice and individual care.
McKeown’s writings on the main drivers of population growth and mortality decline in the early industrializing countries spawned vigorous debates. In addition to economic growth and improvements in food intake and nutritional status which McKeown himself highlighted, others argued also for the population health impacts of birth spacing and family size, housing and sanitary reforms (sewage disposal), and clean water and safe milk supplies (pasteurisation and eradication of bovine TB from livestock herds).
Mortality from typhus fever, a major killer in the 19th century, had shown continuous decline over the ensuing decades in the UK, such that by 1906, three years before Charles Nicolle discovered that the body louse transmitted typhus, London County Council reported no more deaths from that disease. Typhus fever, closely associated with poverty, poor housing, overcrowding, and poor hygiene was much less common among the middle and upper classes in 19th century England. Its decline was arguably linked to the increased availability of public baths, wash-houses, and widening use of cotton clothing, particularly underwear, which allowed for improved personal cleanliness.
Sonja and John McKinlay similarly concluded from their historical analyses that the fall in infectious diseases between 1900-1973, which accounted for 69% of the overall decline in US mortality during that period, could only be explained to a very limited extent (about 3%) by medical intervention.
In retrospect, the Lalonde Report might perhaps be judged prophetic (or lucky), given the as yet limited evidence base which might have restrained a more cautious technocracy professing evidence-based policy and practice. In any case, the thesis was reinforced by subsequent findings from Sweden, France, Ireland, and Hungary, which supported the view that social and environmental changes were the key factors in their decline in infectious mortality.
By the time of the Alma-Ata declaration, these findings from medical history and population healh were resonating strongly with more contemporary experiences from community-based primary health care in China, Bangladesh, Kerala, and Cuba. Notably, both perspectives shared a similarly broad vision of disease causation, rooted in what might be called a social ecology of health and disease.
Population health strategies in particular, according to the Canadian Advisory Committee on Population Health, address the entire range of factors that determine health, in contrast to traditional health care which focuses on risks and clinical factors related to particular diseases. Population health strategies furthermore are designed to affect the entire population, rather than individuals one at a time who already have a health problem or are at significant risk of developing one.
By the late 1980s, critics had highlighted weaknesses in the arguments of McKeown: the relative contributions of fertility and mortality changes to population growth during the period in question, the early conflation of TB mortality with pneumonia and bronchitis (affecting the timing of TB’s decline), the under-emphasis of water supply and sanitary reforms from the 1870s on, and to a lesser extent, the contribution of isolation and quarantine to the control and reduction of infectious disease. The decline of child labor (and its associated early life effects on adult health) has been proposed more recently as a contributory factor from the 1850s onwards, but this too is contested.
On the limited contribution of medical interventions to population health however, there was much less disagreement. Simon Szreter, who had played a prominent role in the critical re-appraisal of McKeown’s work, summed up the consensus thus: ‘The medical profession’s scientific leaders have, since McKeown’s time, had to change their tack and concentrate on the future, rather than the past, as the field in which they can stake the claim that they can save humanity from all its ailments with science.’
In less grandiose terms, the claim might be more plausible in the less developed countries, which still had (and for many still continue to have) large burdens of infectious disease in the mid-20th century, at a time when modern biomedical science in principle could have had a more significant impact on public health and in patient care (with vaccines, antimicrobials and control of disease transmitting organisms).
The availability of diagnostics and the ongoing campaigns for access to anti-retrovirals for instance testify to the potential impact of biomedical science for the public health control of the HIV pandemic. Access to lifesaving treatment for infected individuals is emphatically a moral and ethical imperative. But a public health approach to anti-retroviral treatment goes beyond an individual focus. Equally important, the availability of effective therapy may in some situations encourage those at high risk to come forward for voluntary testing, and hence reduce the pool of infected-but-unaware individuals who constitute one of the drivers of the pandemic.
It is nonetheless noteworthy that the population health perspectives pioneered and promoted by McKeown and Lalonde continue to be relevant to modern epidemics. The SARS epidemic outbreak of 2002-2003 subsided largely in the absence of reliable diagnostics, vaccines, or efficacious therapies, notwithstanding the rapid success in isolating and sequencing the SARS coronavirus. Its control was credited to established public health measures such as isolation, contact tracing, ring fencing, and quarantines, and the economic and financial stakes involved ensured that SARS would not be a ‘neglected disease’.
Likewise, the Nipah outbreak in Malaysia (1998-1999) was rapidly brought under control without vaccines or efficacious therapies, once the modes of transmission were established. The knowledge that Nipah encephalitis was linked to a newly recognised paramyxovirus which could be transmitted through close proximity to live, infected pigs but not via insects, or suspended airborne particulates, or contact with raw or prepared meats (ascertained from virological studies, field epidemiology, and clinical medicine), allowed for its rapid control in humans, even as this control decimated the pig farming industry in parts of Southeast Asia.
These recent experiences, thirty years on, teach us that modern biomedical science has an important integral role to play in informing the social ecological perspective which undergirds PHC for the 21st century.
In appraising this contribution of modern biomedical science to disease control and population health, it is, however, useful to distinguish between its contribution to knowledge-based practices and coping responses, as opposed to an undue focus on commodifiable consumables. This distinction (neatly demonstrated by the Nipah example) is especially pertinent in ensuring that advances in biomedical science in support of PHC are not left the strategic priorities of market-driven research and product development, but are backed by publicly funded and rationally deployed needs-driven research in the biomedical sciences.
This editorial comes from the joint EQUINET newsletter issue with Pambazuka for the thirty years of Primary Health Care. For further information on the issues raised contact admin@equinetafrica.org or ckchan50@yahoo.com.
2. Latest Equinet Updates
The last two issues of EQUINET news have given focus to Primary Health Care (PHC), noting the thirty year anniversay of the Alma Ata declaration on PHC in 1978. The PHC philosophy recognises the need to tackle the broader social and political determinants of health, and involves wide-ranging action to promote health equity. It is focused on improving population health and generating health equity; on inter-sectoral action to address other social determinants of health and is based on social empowerment and comprehensive, integrated and appropriate health care, that emphasises health promotion and prevention and assures first contact care. EQUINET thus sees PHC oriented health systems as a basis for improving equity in health and in access to health services. This month we are making available on our website in electronic form our book "Reclaiming the Resources for Health", a resource that gives the argument for people centred, PHC oriented health systems in east and southern Africa. We report on the resolutions of an important meeting of parliaments health in east and southern Africa held in September 2008 on health equity and PHC, and we present new evidence gathered and methods for advancing PHC oriented health systems. We also present two editorials from our joint issue with Pambazuka news on PHC: Thirty years on. We invite comment and input on PHC in east and southern Africa to admin@equinetafrica.org!
This paper investigates the impact of the framework and strategies to retain critical health professionals (CHPs) that the Zimbabwean government has put in place, particularly regarding non-financial incentives, in the face of continuing high out-migration. The study investigated and reports on the causes of migration of health professionals; the strategies used to retain health professionals, how they are being implemented, monitored and evaluated and their impact, in order to make recommendations to enhance the monitoring, evaluation and management of non-financial incentives for health worker retention. The field survey results showed that Zimbabwe is losing experienced CHPs, but that even newly qualified staff aspire to migrate to gain experience. The major factor driving out-migration is the economic hardship that CHPs face due to deterioration in the country’s economy. Other factors identified include poor remuneration, unattractive financial incentives and poor working conditions. The Zimbabwe Health Service Board (ZHSB) has implemented a retention package but constraints in its adequacy and coverage appear to have limited its impact, whilethe ZHSB itself has limited autonomy to decide on health worker incentives.
The Regional analysis of Equity in Health in East and Southern Africa presents a synthesis of the evidence gathered from a range of sources: published literature on and from the region, reviews of current evidence, where available, data drawn primarily from government, intergovernmental, particularly Africa Union and UN sources and the less commonly documented and heard experience within the region, found in grey literature, in interviews and testimonials and gathered through participatory processes. The report is written for many audiences. For the diverse community involved in health equity within east and southern Africa, it provides a source book of evidence and analysis to support and advance work.
New information can be found at the website for the EQUINET Conference September 2009 on pre and post conference workshops. Regional workshops will be held on issues covering health literacy, policy analysis, participatory methods, writing skillsand health financing. Visit the website at ww.equinetafrica.org/conference2009/index.php for further information. Places are limited so we urge youto register early.
Implementing any policy or intervention faces a range of challenges, especially for those seeking to benefit the poorest social groups. Much public health analysis focuses on the technical aspects of good policy design. However, experience shows that it can be more difficult to deal with the political and institutional barriers to implementation than to design new policies and programmes. Predicting and managing these political and institutional factors is essential to make the changes necessary to strengthen equitable health systems. This guidance brief outlines the frameworks and tools usedin health policy analysis for investigating and tackling these issues. It also presents a range of resources in Africa and elsewhere to support this key area of work in health.
Devoting 15% of domestic public funds to the health sector is necessary - both to address the health and health care needs within east and southern Africa (ESA) and to ensure progress towards building a universal and comprehensive health system. The target of 15% is not unrealistic – it is very much in line with levels of public spending in other countries around the world. Achieving the 15% target demands that public funds not be consumed by debt servicing, so rapid implementation of debt cancellation is critical. The 15% is understood to mean domestic public spending on health, excluding external funding. This policy brief provides information on progress towards meeting the Abuja commitment in east and southern Africa, the obstacles and challengesto address,and the arguments for enhanced effort to prioritising health in national budgets.
The Regional Meeting of Parliamentary Committees on Health in East and Southern Africa on Health Equity and Primary Health Care: Responding to the Challenges and Opportunities, Munyonyo Uganda September 16-18 2008, gathered members of parliamentary committees responsible for health from twelve countries in East and Southern Africa, with sixteen technical, government and civil society and regional partners to promote information exchange, facilitate policy dialogue and identify key areas of follow up action to advance health equity and sexual and reproductive health in the region. This document presents the resolutions of the meeting,and the immediate and long term commitments made by the parliamentarians and their partners towards advancing health equity and Primary Health Care in the region.
SAFM is the largest English language current affairs radio station in South Africa. In its 'Workers on Wednesday' slot the host, live studio guests and call-in audience discussed the reasons for migration of health workers - from rural to urban areas, from the public to the private sector, and from South Africa to other countries - and the effectiveness of incentives to retain health workers in the South African public sector.
On October 23rd 2008 the Community Working group on Health (CWGH) held a national conference gathering district and national members, and an evening event in Harare, Zimbabwe to mark its tenth anniversary. Speakers from civil society, parliament, state and from the region reflected on the challenges to people centred health systems and the contribution of the CWGH. EQUINET joined in this event to present evidence on progress and challenges towards health equity in Zimbabwe and to launch the EQUINET book, "Reclaiming the Resources for Health". The delegates to the conference identified areas for follow up action to promote health equity, including advocating for the right to health to be included in the constitution, and a priority for resources to be directed to resotring the environments for health and to investments in primary health care.
3. Equity in Health
Civil society organizations and scientists from around the world are calling for 'a new development paradigm' to address the toxic combination of climate change, growing poverty and inequality and poor health. The new report, Global Health Watch 2, says that unfair social and economic policies combined with bad politics are to blame for the poor state of the health of millions of people in the world. The report makes stinging criticisms of key global actors, and calls on governments to stop the Bank from meddling in health politics. Global Health Watch 2 provides examples of civil society mobilization across the world for more equitable health care and more health promotion, although more is needed to bring about significant improvements in health.
This paper analyses the concept of health equity, drawing on ideas of social justice, of rights and values, and of the social and economic determinants which define living conditions and power relations among social groups. It adopts the viewpoint of collective health and outlines the elements which are essential to the understanding of inequity: the role of social, economic, political, cultural and ideological determinants on the equity of health outcomes, access to services and quality of care. It concludes that theoretical/conceptual frameworks must be formally spelled out before we can advance our understanding of health equity. From a collective health perspective, we need to move beyond traditional approaches, a challenge which will enable better understanding of the social dynamics which, when expressed as inequalities in health, constitute social inequity.
Significant progress towards reducing child and maternal mortality is being made, but to meet the Millennium Development Goals (MDGs) 4, 5 and 6, strategies aimed at reaching the world’s most inaccessible, marginalised and vulnerable populations will be required, according to Ethiopia’s Minister of Health and the heads of four leading global health organisations – the GAVI Alliance, UNAIDS, the Global Fund to Fight AIDS, TB and Malaria and UNICEF. Many countries are committed to achieving the MDGs but rely largely on donor support for its national health plan to continue its progress. Increased funding has seen improved immunisation rates, more programmes against malaria (by providing insecticide-treated bed nets) and the expansion of anti-retroviral access to two million in sub-Saharan Africa have contributed to an improving health picture for the continent, with reductions in mortality and morbidity rates.
Why a renewal of primary health care (PHC), and why now, more than ever? Globalization is putting the social cohesion of many countries under stress, and health systems are clearly not performing as well as they could and should. People are increasingly impatient with the inability of health services to deliver. Few would disagree that health systems need to respond better – and faster – to the challenges of a changing world. PHC can do that.
This report is based on a master set of data that has been compiled by an inter-agency and expert group on Millennium Development Goal (MDG) indicators, led by the Department of Economic and Social Affairs of the United Nations Secretariat, in response to the wishes of the General Assembly for periodic assessment of progress towards the MDGs. The group consists of representatives of the international organisations whose activities include the preparation of one or more of the series of statistical indicators that were identified as appropriate for monitoring progress towards the MDGs. This report summarises progress towards the Goals in each of the regions. However, any such synthesis inevitably masks the range and variety of development experiences in individual countries since the goals were adopted.
4. Values, Policies and Rights
Human rights provisions addressing technology have been much ignored but are starting to receive renewed interest, mainly regarding patent disputes, stagnation in publicly funded research, and the role of technology in meeting the Millennium Development Goals. This study analyses articles 11.2(a) and 15.1(b) of the International Covenant on Economic, Social and Cultural Rights (ICESCR), as well as the Convention on Biological Diversity and the International Treaty on Plant Genetic Resources for Food and Agriculture, neither of which assume any conflict between technology and the environment. International cooperation for the realisation of the right to food is widely acknowledged, including technological efforts to produce more high-yielding varieties. Human rights treaties, especially in the ICESCR, can help guide the formulation and implementation of technology policies.
This initiative aims to reduce maternal mortality by holding governments accountable for implementing effective and equitable policies and programmes, securing increased resources at the global and national levels and promoting understanding among, and providing expertise to, key stakeholders on addressing maternal mortality as a human rights issue. It was founded by the AMDD program at Columbia University, CARE, the Center for Reproductive Rights, Family Care International, Physicians for Human Rights, and the UN Special Rapporteur on the right to the highest attainable standard of health, Paul Hunt. These diverse organisations with different perspectives have joined together to use human rights in the struggle against maternal mortality.
The recently released World Health Report on PHC (WHO Oct 2008) is an attempt to bring PHC again to the forefront of our priorities in global health. But to go beyond well-meaning pronouncements, this will clearly need some internal reorganisation in this UN agency. The question is whether its leadership plans such a re-orientation? PHM does not shy away from a political approach to PHC and is not really fighting its opponents; it is rather bringing the level of the discussion to a higher level. PHM challenges the concept that good health is an imperative for increased economic productivity. Instead, it insists that health is an inalienable human right. Health is not either a technical or a political issue – it is both – and pro-poor health interventions mean nothing if not concomitantly accompanied by poverty reduction actions that are pro-health.
5. Health equity in economic and trade policies
While world leaders gathered in New York for a high-level meeting last month in New York on the Millenium Development Goals (MDGs), international development agencies, including Britain's Christian Aid, warned that progress is being hampered by the activities of rich countries and big business. Christian Aid said that the problems were due to short-sighted trade liberalisation imposed on poor countries and the use of offshore havens by transnational corporations to reduce their tax liabilities in the developing world, grievously undermining international aid efforts. The aims of the MDGs were wholly desirable but rich countries were likely to argue about how much more aid they could afford, instead of addressing trade liberalisation and offshore havens.
Economic partnership agreements were one of the topics discussed at the 6th African, Caribbean and Pacific Summit of Heads of State and Government held in Accra, Ghana from 30 September to 3 October. African, Caribbean and Pacific countries decided whether to sign agreements that they have initialled, re-negotiate them or expand interim goods agreements further. Among the conclusions of the analysis of this topic are that the provisions on movement of capital and entry of EU providers of financial services may magnify the problem of instability that new financial services generate, and that the developing countries would have to undertake obligations in market access and rules in new areas (investment, government procurement, competition policy) that had been rejected as negotiating topics in the WTO. For example the right to regulate services has been narrowed further than GATS, universal service provision will be more limited.
The Executive Coordinator of the Millennium Campaign has called for coherent global collaborative action to effectively deal with trade imbalances suffered by developing countries. Addressing the inaugural Geneva Trade and Development Forum at Crans-Montana, she bemoaned the current situation where developing countries are left fragmented in negotiating processes: ‘It is time to make trade policies part of the broader relationship, not just with other countries, but, more importantly part of the broader agenda of challenges of global poverty, the environment and security.’ Included in the agenda should be the issues of public health, food security and nutrition, as well as the relationships among the three.
Some developing nations nave accused developed nations of overreaching themselves in their push to escalate enforcement of intellectual property rights and want their efforts to be reined in and centralised in the World Intellectual Property Organisation. This especially applies to a secret negotiation led by the United States, Europe and Japan to create an Anti-Counterfeiting Trade Agreement (ACTA). The ACTA might create trade barriers and harm consumers, domestically and outside the signatory nations. The agreement lacks ‘democracy’ and balance, as it relies heavily on industry groups and rights holders with no representation on behalf of consumers. And as the law enforcement side rises, individual legal rights may be diminished. Secrecy around the treaty negotiation has fuelled speculation that its terms will undermine vital consumer interests, including access to low-cost generic medicines.
This paper from the South Centre is concerned with the widening development gap in the setting of new international policy regimes and a changing global economic environment. It discusses participation and developing country governance adaptation issues in the WTO and in the UN Conference on Trade and development (UNCTAD). It concludes that developing country group action should be an essential component in global trade governance. Inclusive governance will require clear policy issue and agenda articulation from shared understanding, institutionalised coordination and group leadership mechanisms, good working relationships between individual country delegates and other developing country delegates, and full and continuous institutional support of high professional quality.
6. Poverty and health
A plan to boost food production in developing countries and provide urgent food aid was discussed by the Development Committee on 10 September 2008. The food price index rose by more than 40% last year, which has had catastrophic consequences for people in the developing world who are already suffering from malnutrition. It has been estimated that to deal with the problem in the medium term it would probably require an extra €18 billion. The EU has committed to finding €1.8 billion over the next two or three years from unspent agricultural money to be matched by money from the Member States. Some of this will be used for direct food support, given the massive fall in grain stocks. Most will be used for seeds, fertiliser and irrigation to help countries to develop and grow their own food.
A new report by Transparency International (TI) has lashed out at some of the world's poorest countries for an ‘ongoing humanitarian disaster’, and deplored the wealthiest for not doing enough to help. At the launch of their 2008 Corruption Perceptions Index (CPI) on 23 September in Berlin, TI said: ‘In the poorest countries, corruption levels can mean the difference between life and death, when money for hospitals or clean water is in play, but even in more privileged countries, with enforcement disturbingly uneven, a tougher approach to tackling corruption is needed.’ The 2008 CPI is a composite index, drawing on different expert and business surveys. It scores 180 countries (the same number as in 2007) on a scale from 0 (highly corrupt) to 10 (very clean). Denmark, New Zealand and Sweden share the highest score at 9.3, followed immediately by Singapore at 9.2. Bringing up the rear is Somalia at 1, slightly trailing Iraq and Burma at 1.3 and Haiti at 1.4.
The UN Secretary-General, Ban Ki-Moon, has warned in a new report that the gains made in reducing extreme poverty are under threat from the rise in global food and fuel prices and global economic slowdown. In the UN’s Millennium Development Goals Report 2008, launched on 11 September, Ban wrote: ‘The largely benign development environment that has prevailed since the early years of this decade, and that has contributed to the successes to date, is now threatened. The economic slowdown will diminish the incomes of the poor; the food crisis will raise the number of hungry people in the world and push millions more into poverty; climate change will have a disproportionate impact on the poor.’
Climate change may affect health outcomes and food utilisation, with additional malnutrition consequences. This paper argues that resources for nutrition, such as agriculture budgets, are inadequate. Appropriate policies should make bioenergy development more pro-poor and environmentally sustainable. Efforts to achieve food security and good nutrition should address the underlying social, economic, cultural and political causes of food insecurity and malnutrition. Some low-income governments are now cutting excessive military spending and allocating more money to the public sector. The paper supports the so-called ‘twin-track approach’ to combating hunger and poverty: strengthening the productivity and incomes of hungry and poor people, targeting rural areas, ensuring direct and immediate access to food by hungry people and putting social safety nets in place.
Less than half of development aid approved by the European Commission is explicitly linked to international objectives on reducing poverty, a new study has found. Health and education assume a central role in the United Nations Millennium Development Goals, which were approved by all of the UN’s member countries in 2000. The eight objectives include targets to substantially reduce illiteracy, deaths of mothers during childbirth and of children before their fifth birthday, and the incidence of major diseases like AIDS, tuberculosis and malaria by 2010. Even though the European Union has undertaken to finance the attainment of these goals, its executive branch or commission appears to be attaching less importance to primary education in poor countries than it did at the start of this decade, according to Alliance 2015, a coalition of anti-poverty groups.
New poverty estimates published by the World Bank reveal that 1.4 billion people in the developing world were living on less than US$1.25 a day in 2005, down from 1.9 billion in 1981. These revised numbers reflect improved household data from a greater number of countries. They are based the International Comparison Programme (ICP) and 675 household surveys covering 116 countries and spanning the period 1981 to 2005. The new numbers show that poverty has become more widespread across the developing world over the past 25 years than previously estimated, but also that there has been strong – if regionally uneven – progress toward reducing overall poverty. On the other hand, they also demonstrate that the developing world is still on track to meet the first Millennium Development Goal of halving extreme poverty by 2015.
7. Equitable health services
Health policy has tended to export models of health systems from developed nations to low-income countries without questioning their appropriateness and adaptability. Debates about the roles of public and private providers are meaningless in poor countries that do not have the institutional framework to govern a market economy and where government has little capacity to regulate providers of health services. The lack of appropriately contextualised debate and language hampers national and international efforts to address major health challenges. Health systems, like other systems of producing social goods, are ways of producing and organising access to expert knowledge and the technologies that derive from it. Their failure, in many contexts, to serve the interests of the poor means we should also be exploring different ways of producing and delivering services rather than simply intensifying efforts to recreate existing ones.
Government, business and civil society leaders gathered at the United Nations to launch a global campaign to reduce malaria deaths, currently at more than 1 million each year, to near zero by 2015, with an initial commitment of nearly a $3 billion. The Global Malaria Action Plan (GMAP) aims to cuts deaths and illness by 2010 to half their 2000 levels by scaling up access to insecticide-treated bed nets, indoor spraying and treatment, and achieve the near-zero goal through sustained universal coverage. Ultimately it seeks to eradicate the disease completely with new tools and strategies.
This report aimed to identify health-care and provider-related determinants of diabetes and hypertension patients attending public sector community health centres (CHCs). A random sample of eighteen CHCs in the Cape Peninsula, South Africa, providing hypertension and diabetes care was selected. Twenty-five diabetes and 35 hypertension patients were selected per clinic and interviewed by trained fieldworkers and their medical records audited. Knowledge about their conditions was poor. Prescriptions for drugs were not recorded in medical records of 22.6% of the diabetes and 11.4% of the hypertension patients. Primary care for patients with hypertension and diabetes at public sector CHCs is suboptimal. This highlights the urgent need to improve health care for patients with these conditions in the public sector of the Cape Peninsula.
Strengthening health systems is a key challenge to improving the delivery of cost-effective interventions in primary health care (PHC) and achieving the vision of the Alma-Ata Declaration. This overview summarises the evidence from systematic reviews of health systems arrangements and implementation strategies, with a particular focus on evidence relevant to PHC in such settings. Although evidence is sparse, there are several promising health systems arrangements and implementation strategies for strengthening primary health care. However, their introduction must be accompanied by rigorous evaluations. The evidence base needs urgently to be strengthened, synthesised, and taken into account in policy and practice, particularly for the benefit of those who have been excluded from the health care advances of recent decades.
Medecins Sans Frontieres (MSF) has made an urgent call for the wider implementation of the newer and more effective anti-malaria strategies in an effort to save lives. Malaria still kills a child every 30 seconds worldwide while nine out 10 of these deaths occur in sub-Saharan Africa, predominantly among young children. According to the World Health Organisation, one in every five childhood deaths is due to the effects of malaria. An MSF report released in Johannesburg on 31 September shows that unnecessary illness and death can be avoided with simple, affordable treatment and diagnostic tools that are currently available. The report follows the launch of an ambitious new Global Malaria Action Plan aimed at reducing the number of malaria deaths to near zero by 2015, with world leaders committing nearly US$3-billion to ensure it succeeds.
Nearly 60 million women will give birth without any medical assistance this year, the World Health Organisation (WHO) has said in a report calling for an overhaul of how health care is financed and managed globally. The United Nations agency said in its annual World Health Report that the billions of aid dollars devoted to fight specific epidemics like AIDS had distracted attention from providing comprehensive care to mothers and children. The difference in life expectancy between the richest and poorest countries still exceeds 40 years, said the report, whose launch coincided with a global financial crisis that could freeze aid flows and squeeze government budgets for health care. Increasingly specialised and technical medicine in wealthy nations has also excluded and impoverished millions of patients, exposing failures of ‘laissez-faire’ governance in health. WHO is encouraging countries to go ‘back to the basics’.
8. Human Resources
The Global Health Workforce Alliance (GHWA) has welcomed the pledges of commitment expressed at the United Nations High Level Meeting on the Millennium Development Goals and surrounding events that place resolving the health workforce crisis at the centre of ensuring progress on improving maternal and child health and addressing killer diseases such as malaria. Significant financial commitments were made to address the health workforce as part of the drive to move closer to the achievement of Millennium Development Goals 4 and 5 on reducing maternal and child mortality. Commitments included a pledge of £450 million from the UK over the next three years to support national health plans, incorporating training more nurses, midwives and doctors in eight of the poorest countries.
African leaders lack the foresight and political will required to ensure sustainable health development, financing and universal primary health care. By underlining the effects of institutional under-funding and the brain drain, the author contends that policy neglect is the equivalent of ‘institutional manslaughter’. Africa’s critical health workforce shortage is arguably the most serious obstacle to implementing global and African health frameworks and universal primary health care across the continent and governments must improve health workforce working conditions. The proper, moral and sustainable solution is to ensure that more developed countries invest in training of adequate numbers of their own health workforce, and that less-developed countries demonstrate full political commitment to training and retaining their health workers –with the support of more-developed countries, where necessary.
9. Public-Private Mix
Diseases that dominate the health of most African populations, such as AIDS, malaria, and tuberculosis, have always received a small proportion of the global financial support available for medical science and health interventions. Of the 1393 new drugs approved in the 25 years before 2000, only 13 were specifically indicated for tropical diseases. Health-related public-private partnership organisations have been supported for decades by the traditional public-sector research funding bodies. These major public-sector funding bodies are located in developed countries and, although the situation is changing, direct access to funding has historically been very difficult (or legally impossible) for researchers from developing countries. As a result, even where developing-country researchers have received research funds from such agencies, most of the funding has been channeled through host country institutions. This creates a dependency relationship, as well as multiple bureaucratic hierarchies in administering such grants.
It is a myth that health in Africa is financed primarily by the public sector. About 36% of funding in Africa is from out-of-pocket payments, with 7% from other private sources and 27% from donors. Only 30% of African health care funding is public funding. In addition, 32% of healthcare access for rural Africans comes from the private sector, and 46% of doctors in sub-Saharan Africa work in the private sector. The for-profit private sector provides significant care for sub-Saharan Africans, across income groups, and this is expected to double by 2016. Since there are not enough resources in the public sector and governments cannot rely forever on development partners (donors) funds, Public/private partnership can help expand the pool of human resources.
Pharmaceutical pricing policies are designed with national objectives in mind, but are the transnational implications always taken into account? This study notes that specific characteristics of the pharmaceutical market have given rise to current pharmaceutical prices. Market-based or ‘free’ pricing is common for products not subsidised by coverage schemes. Price regulation exists in most countries but does not necessarily result in lower prices because prices are determined by the respective market powers of the parties involved. Many other types of policies, other than those directly related to pricing, affect the pharmaceutical market and even if policy makers hold common objectives, they may weight them differently when trade-offs are required. More investment incentives for research and development are needed.
This Guidance Note is based on the proceedings of the meeting and offers policymakers and researchers the latest evidence on private-provider networks and franchises, lessons learned in the field, and policy recommendations on how to mobilise private-provider networks and health franchises to help address reproductive health care needs in developing countries. Recent evidence from sub-Saharan Africa indicates that about a third of all family planning methods are obtained through the private sector. For the poor, these expenses can be substantial, even catastrophic. Although specific public policy efforts regarding the private sector largely depend on individual country context, three broad approaches may be useful in guiding discussions: (i) Expanding healthcare access by engaging a range of private sector providers; (ii) Harnessing and organising existing private sector providers into a cohesive network to improve quality and ensure equity; (iii) Shifting the burden of public financing of private healthcare sector among those able to pay for its services.
10. Resource allocation and health financing
About 11 million of 33 million HIV-positive people have tuberculosis (TB) and, if financially troubled nations renege on aid pledges, it would deprive the poor of life-saving treatment. New Nobel laureate and HIV co-discoverer, Francoise Barre-Sinoussi, fears that the global economic crisis could cause nations to renege on commitments to fight tuberculosis and wipe out gains made against AIDS because so many people suffer from both diseases. The world is achieving success with antiretroviral treatment for HIV, but we have an epidemic of multi-resistance to tuberculosis treatment, which is really alarming. An estimated 33 million people worldwide are infected with HIV. About 11 million of them also have tuberculosis. By suppressing the immune system, HIV leaves people susceptible to other infections, especially TB.
The provision of universal access to healthcare, a right enshrined in the South African Constitution, is the responsibility of government. Although much progress has been made towards the creation of a national health system which makes ‘access to health for all’ a reality, much remains to be done. As a means to facilitate debate on the subject, the Policy Analysis Unit of the HSRC hosted a colloquium on ‘Health within a comprehensive system of social security’. The main purpose of the colloquium was to initiate policy dialogue and critical discussion on how health services are accessed, provided and funded – and to formulate ideas, views and recommendations that could be presented to those involved in health policy development. This publication contains the keynote addresses and a summary of deliberations that emerged from the colloquium.
The United Nations has teamed up with world leaders to launch a new initiative to strengthen health systems in an effort to reduce the number of women who die in pregnancy and childbirth, one of the eight Millennium Development Goals (MDGs), with a 2015 deadline. The task force on maternal mortality, which will be co-chaired by British Prime Minister Gordon Brown and World Bank President Robert Zoellick, will focus on innovative financing to strengthen health care systems and pay for health care workers. The recommendations that will flow from the group, which will include UN World Health Organization (WHO) Director-General Margaret Chan and several global leaders, will potentially save the lives of 10 million women and children by 2015. They will be presented to next year's meeting of the leaders of the Group of Eight (G-8) industrialised nations, to be held in Italy.
11. Equity and HIV/AIDS
Anti-retroviral therapy (ART) scale up in Malawi continues to progress well. Sites are doing well, despite the increasing burden of work. The majority are taking the initiative of doing quarterly and cumulative cohort analysis, although nearly one third of sites are still not coming up with correct outcomes. This will require continued and regular vigilance and supervision. The treatment outcomes for ART are reasonable. Early death rates are still a problem, and defaults still constitute a significant proportion of the outcomes. ARV drug stocks were again assessed, and nationally drugs stocks are adequate. However, some sites are over-performing to a large extent and causing problems with drug stocks (both for starter packs and continuation packs). The quarterly drug stocktaking assists in the activity of re-distributing drugs from under- to over-performing sites. Some drugs for HIV-related diseases, particularly morphine and vincristine, are out of stock in most facilities.
This study aimed to determine important factors that affect antiretroviral drug adherence among HIV and AIDS male and female adult patients in Kenya. A cross sectional study involving 384 adult patients on ARV drugs and attending Moi Hospital, Eldoret, was conducted. Sixty-eight percent of the respondents on ARVs were females aged between 18-63, of which 52.1% had secondary and post secondary education. Results showed that only 43.2% adhered to the prescribed time of taking drugs. Only 93.5% of the respondents kept clinic appointments. It recommends patients should be educated on the importance of strict adherence to the prescribed doses of ARVs as a suitable measure of intervention. Future research should explore multiple-target interventions to resolve barriers to adherence.
Malawi is one of the countries experiencing an unprecedented HIV/AIDS epidemic in an environment where malnutrition is rampant. In 2001 Malawi started providing ARVs to HIV patients. This ARV programme is now being scaled up to cover the whole country. Since underlying malnutrition is associated with adverse ART outcomes, the Malawi government commissioned a study to design a programme for integrating nutrition in the ARV scale up plan. This study used a Participatory qualitative research methodology. The study recommends that nutritional support should include therapeutic feeding, food supplements and take home ration and proposes a clear enrolment and discharge criteria.
Children living with HIV in Uganda have been given greater access to treatment with a new paediatric HIV care centre opened at the main referral hospital in the capital, Kampala. More than 20,000 children are infected with HIV every year, and 50 percent of them die before their second birthday. There is still inadequate access to paediatric HIV care and treatment services in Uganda –out of the 330 active antiretroviral therapy centres in Uganda, only 110 are able to provide paediatric HIV care services, and most of these are located in urban centres. The centre at Mulago Hospital is the first to provide a comprehensive package of HIV care and treatment services for children and adolescents infected or exposed to HIV, including testing, treatment, counselling of children and their families, and training healthcare professionals in the management of paediatric HIV.
The study's first objective was to determine the levels of patient satisfaction with services at antiretroviral treatment (ART) assessment sites. Four cross-sectional waves of data were collected from a random sample of 975 patients enrolled in the Free State's public-sector ART programme. With respect to both general services and the services provided by nurses, results indicated high overall satisfaction among Free State patients receiving public-sector ART. However, the data presents a less positive picture of patient satisfaction with waiting times. Significant geographical and temporal differences were observed in these three aspects of patient satisfaction, according to the district surveyed. Patients attending facilities with high professional nurse vacancy rates reported significantly less satisfaction with nurses' services than did those attending facilities with fewer vacant nursing posts.
The United States Agency for International Development (USAID) has instructed its staff to force governments in several African countries to discontinue the provision of US-funded contraceptive commodities to Marie Stopes International (MSI), one of the world’s leading family planning organisations. USAID claims MSI works with the Chinese Government, whom the US State Department accuses of ‘coercive abortion and involuntary sterilisations’. MSI denied that MSI supports coercive abortion or involuntary sterilisation in China or elsewhere. It said the instruction will ‘seriously disrupt’ MSI’s family planning programmes in at least six African countries – Ghana, Malawi, Sierra Leone, Tanzania, Uganda and Zimbabwe - including one where the organisation delivers 25% of all family planning services nationally. Women in these countries will be left with few options other than unsafe abortions, resulting in death or disability.
On 28 May 2008 the Institute of Tropical Medicine (Antwerp, Belgium) hosted a meeting at the World Health Organization (Geneva, Switzerland) to review the evidence on the effects of AIDS programmes on Health Systems, particularly in high HIV prevalence settings, and discuss the way forward. Over 30 participants attended from a range of backgrounds (implementers, activists, academics and funders) and HIV-affected countries. The report summarizes the main issues that were discussed at the workshop, including the harms and benefits of HIV programmes for health systems and primary health care, debates around continued AIDS exceptionalism, and considerations and policy options for HIV programmes
to maximise their potential to contribute to health systems strengthening.
The report is organised around the major issues/debates that have been raised around AIDS programmes and health systems, particularly the financing, organisation and delivery of health systems. The discussions were informed by country experiences presented from a number of high-burden countries in sub-Saharan Africa and evidence and experience from
meeting delegates.
12. Governance and participation in health
These guidelines aim to assist practitioners and implementing partners to run community-based worker (CBW) systems more effectively, maximising impacts for clients of the service, empowering communities, empowering the CBWs themselves, and assisting governments to ensure that services are provided at scale to enhance livelihoods. They are aimed at practitioners in government, civil society or the private sector already involved or interested in the practical application of community-based worker models. Topics include the generic components of the CBW system, deciding where to use a CBW approach, preparing for implementation and operationalising the CBW system. Descriptions are provided for the different elements of the system, along with step-by-step guidance.
The aim of the Round Table was to build upon the work of the Advisory Group on Civil Society and Aid Effectiveness (AG-CS). A first point of consensus to emerge from RT6 was recognition of the many roles of civil society, and of the importance and value of civil society organisations (CSOs) as development actors in their own right and as aid recipients, donors and partners. A way forward was proposed, involving donors, governments, and CSOs themselves, and shared leadership for different aspects of this work. It includes working together to provide a more enabling environment for CSOs, working on how CSOs can develop more effective partnerships with each other, including North- South, South-South, global networks and national umbrella organisations, offering support for the CSO-led Open Forum for CSO Development Effectiveness and preparing the ground for CSO engagement in the High-Level 4, ensuring that a multi- stakeholder perspective on CSO effectiveness is a major theme of HLF4.
Malawi is poised to drastically expand safety nets to orphans and their families, and this study will provide an important foundation for this process. The study analysed nationally representative data from 27,495 children in the 2004–2005 Malawi Integrated Household Survey. It found that friends and relatives provided assistance to over 75% of orphan households through private gifts, but organised responses to the orphan crisis were far less frequent. Over 40% of orphans lived in a community with support groups for the chronically ill and about a third of these communities provided services specifically for orphans and other vulnerable children. Public programmes, which form a final safety net for vulnerable households, were more widespread. Free/subsidised agricultural inputs and food were the most commonly used public safety nets by children's households in the past year and households with orphans were more likely to be beneficiaries.
Proposed reforms to the way the World Bank is governed tinker at the edges, promising only marginal improvements for developing countries; critics are stepping up the pressure for a fundamental rethink. The World Bank board will discuss a package of reforms to the way the Bank is governed at its annual meetings in October, hoping to agree a concrete set of actions by next spring. Despite calls from developing countries, civil society and others for root and branch change to address the Bank's gaping deficits in democracy, legitimacy and accountability, the proposals are uninspiring.
13. Monitoring equity and research policy
This newsletter highlights areas of work for the Alliance for Health Policy and Systems Research (Alliance-HPSR), including the Bamako Ministerial Forum on Research for Health; identifying priority research questions; enhancing policy maker capacity to use evidence; and the International Health Partnership and what it means for health systems.
This is the final statement of a meeting held in Nyon, Switzerland, 25–27 May 2008 between the Alliance for Health Policy and Systems Research, WHO and the International Development Research Centre, Canada. Considerable progress has been made in established health policy and systems research (HPSR) areas such as health financing, worker relations and the role of the non-state sector, though achievements in these areas vary substantially. In some, such as health financing, a large number of studies and recent reviews have began to synthesise findings; in others, such as HRH, relatively limited empirical work has been conducted and there is a need to intensify research efforts. There is an urgent need to move from research that is descriptive and identifies problems, to research that is action oriented and helps develop and evaluate potential solutions. Stronger links among researchers, policy makers and research and development funders are required to facilitate this. Despite interesting work in the field, HPSR continues to be perceived as the poor relation to more basic health sciences research. More must be done to highlight the positive contributions that HPSR can make to the big health issues of our time.
The introduction of information and communications technology into a developing nation setting poses unique challenges. A recent randomised controlled trial done in Luanda, Angola, surveyed 231 people to assess their risk for HIV infection. In half of the surveys, the interviewers used a PDA to note participant responses. In the other half, the interviewers used paper and pencil. Other than the difference in these tools to record responses, the two groups were essentially the same. People in the PDA group gave, on average, 2.4 socially desirable responses (out of 9 possible), compared to 1.4 for participants in the paper-and-pencil group. That is, people seemed to exaggerate how safe their behaviours were when they were faced with an interviewer using a PDA. This finding suggests that the good intentions of introducing ICT into health-care settings in low-income countries may have unintended consequences if tests of its effects are not done beforehand.
According to the 2008 Basic Capabilities Index, the Millennium Development Goals will not be achieved by 2015 at the present rate of progress, unless substantial changes occur. Progress in basic social indicators slowed down last year all over the world. Out of 176 countries for which a BCI figure could be computed, only 21 registered noticeable progress in relation to their score in 2000. Another 55 countries showed some progress, but at a slow rate, while 77 countries stagnated or worsened. Information is insufficient to show trends for the remaining 23. As the impact of the food crisis that started in 2006 begins to be registered by the new statistics coming in, the situation is likely to get worse in the next months.
14. Useful Resources
If you or your colleagues are facing difficulty in your project monitoring and evaluation reports, the Reporting Skills and Professional Writing Handbook (2nd Edition) is a self-study programme based on the best of ten years' experience running hundreds of training courses. There's a free download of the first module and you need to sign up to receive the remaining modules, free. It is designed to save time and help your team turn out more effective progress and evaluation reports. The programme is also available on CDROM for convenient desktop study, and, for larger organisations, the Trainer Edition is supported by a complete Training Pack.
GuideStar International (GSI) seeks to illuminate the work of civil society organisations (CSOs) around the world. It is based in the UK. Their new website, in co-operation with the United Nations Economic Commission for Africa (UNECA), was started as a joint venture to develop a free web portal for African civil society, showcasing NGOs, charities, non-profit organisations and community-based organisations, ranging from the smallest to the largest. Utilising a shared internet platform, organisations will be able to display their vision and mission, objectives, activities, needs and finances to donors, researchers, policy makers and the general public.
To coincide with the high-level meeting last month in New York on the Millenium Development Goals (MDGs), the International Disability and Development Consortium (IDDC) and the Millennium Campaign have launched a new web site on disabilities and the MDGs. The site aims to raise awareness among the general public, NGOs, donors and governments about the need for the MDGs and poverty reduction programmes to address disabilities. One in five of the world's poorest people are disabled, yet they are rarely considered in MDG health plans and programmes. With the recent report from the Commission on the Social Determinants of Health, this is a timely moment for the health community to consider disability as a barrier to accessing health services. The website is a work in progress and the IDDC wants to link it to other sites, sources and organisations.
The Right to Food and Nutrition Watch provides a systematic compilation of best practices for the realisation of the right to food and also documents where violations have been committed. The Zero Issue deals with the topic ‘The World Food Crisis and the Human Right to Food’ and gathers articles and country monitoring reports from different experts and regions (the Americas, Asia, Africa and India). The publication also discusses the most recent global trends affecting the right to food, such as the increased expansion of agrofuels, and sheds new light on practices that continue to impede the realisation of the right to food, such as mining and the mismanagement of social cash transfers. UN experts on human rights and the right to food also give their input on recent UN documents and sessions. The hard copy of the Right to Food and Nutrition Watch is accompanied by a CD-ROM that includes supporting documents and full reports of all content.
15. Jobs and Announcements
The Seventh World Congress on Health Economics will be taking place in Beijing 12-15th July 2009 on the theme 'Harmonizing Health and Economics'. Submission of abstracts and session proposals is open until 15 November 2008. This forum is accepting an increasing proportion of abstracts from low and middle income countries. More information about the topics and pre-congress symposiums is available on the website.
The Wellcome Trust and the Alliance for Health Policy and Systems Research recognise the importance of using health research evidence in policymaking. This joint call for proposals is focused on low income countries and intends to build much needed capacity to strengthen links between research and policy making. Proposals are invited from groups based in low income countries to: Develop and implement innovative interventions that enhance policy maker capacity and/or civil society capacity to employ health policy and systems research evidence in policy making and policy dialogue; and conduct rigorous evaluations of the strategies employed. All proposals must address both of these objectives. Brief expressions of interest should be submitted to the Alliance by 16 January 2009.
The HIV Clinical Group at Pretoria University, in conjunction with PIJIP and WCL clinic students, is working to prepare and garner widespread NGO support for a submission before the African Commission during its meeting in Abuja, Nigeria from 10–24 November. This submission will call upon the African Commission to adopt an interpretation of the right to health under the African Charter, which mirrors the one provided by General Comment 14 to the ICESCR, specifically recognising that access to medicines is a crucial component to the right to health. Furthermore, upon recognising that the right to health includes the components of accessibility, availability, acceptability, and good quality of medicines, the submission will call upon the African Commission, in the future, to use these standards as a means to uniformly monitor state's compliance with the right to health.
From 27 January to 1 February 2009, the city of Belem, Brazil will host the World Social Forum. Hundreds of self-managed activities – as campings, workshops, seminars, conferences, testimonies, marches, cultural and artistic activities, among others – during this six days will be spaces for exchange, reflection and building of proposals for another possible world. The registration to participate in WSF 2009 starts in October and can be made via the website address.
Published by the Regional Network for Equity in Health in east and southern Africa (EQUINET) with technical support from Training and Research Support Centre (TARSC).
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