The word “crisis” is becoming more common than water. Multiple crises are converging- economic, climate, energy, food and social. After a long period of speculative financial boom, media in the wealthy countries of North America and Europe are filled with apocalyptic stories of financial crisis, unnerving the people in these countries, who still collectively hold almost 90% of total world wealth. For the half of the world’s adult population who own barely 1% of global wealth, however, the crisis has been going on for decades.
The chronic crisis for this significant majority of the world’s people has been evident in more than a generation of unemployment, landlessness, loss of assets, and deprivation, that has further grown during the financial booms of the last decades. During a period characterised as “economic success” in the highest income countries, malnutrition and food insecurity grew in the poorest countries in Africa, falling international prices reduced returns on production and a food supply chain increasingly controlled by a few transnational corporations was able to further drive down producer prices, especially threatening women smallholder food producers. What was a boom for the import/ export firms, shipping companies, large-scale farm enterprises, financiers and officials who tapped into these commercial and financial circuits, was a deepening economic and social crisis for women and children.
In 2008 attention began to be paid to this food crisis. Like the financial crisis, the food crisis has been growing over decades of aggressive agribusiness. The scale and cost of this liberalized and speculative food production system is now, however, outstripping the possibilities of the usual emergency relief response. The alarming increase in child malnutrition in east and southern Africa post 1990 signals the failure of this model of agriculture for the populations of the region, even while it offered growing profits for largely foreign owned agribusiness.
Repeated outbreaks of disease also signal that people, usually in poor communities, are bearing the brunt of failed policies. Cholera is an avoidable disease that is prevented through safe water and sanitation systems. Zimbabwe has experienced a growing cholera crisis since August. By the first of December the United Nations reported 11,735 confirmed cases of cholera and 484 deaths in Zimbabwe. With the decline in functioning of clean water supplies, people’s mobility and a breakdown of the health sector’s capacity to contain the disease, the cases and fatalities continue to rise. Notwithstanding the economic decline in the country, Zimbabwe has the national wealth to secure basic water supplies and health care. The Zimbabwe Doctors for Human Rights correctly call the failure to do so a violation of human rights.
The globalization of media brings these crises to public attention with increasing speed. But does increasing awareness of such crises bring change?
While change often emerges from crisis, the last three decades suggest that this is not inevitable, particularly if the response fails to challenge the causes of the crisis.
The current financial crisis is possibly the deepest in recent history, but not the first. When the long boom of post-war economic growth ground to a halt in the 1970s, the response to financial decline was an aggressive pursuit of market policies, liberalisation and the opening of countries to transnational corporations. In the 1980s, after a spree of private bank lending, when heavily indebted countries were unable to pay back loans, the International Monetary Fund stepped into the financial crisis to bail out the Northern banks by offering loans to the indebted countries, restructuring their economies towards even greater liberalisation and market reform. These responses have generally served to protect existing wealth and the liberalised and speculative models of economic development that have both deepened inequality and that have been associated with the current crisis.
The response to the current financial crisis has starkly demonstrated the choices made over what merits protection. We have for some time known from United Nations data that saving several million lives annually by bringing safe water and sanitation to all would cost $10 billion a year. This money has never been found. Yet in October 2008, in one week, the US government provided a bail out package to the banks of $250 billion, 25 times this amount.
We are also seeing signs in the response of an efficient global machinery shifting the burdens of the financial and food crisis to the most vulnerable. According to the international non government organisation, GRAIN, players in the finance market - investment, equity and other funds – are turning to land as a strategic investment asset and haven for investment funds, even while the food and fuel crisis are driving acquisition of land for wealthy populations food and fuel needs. The organisation’s website lists over 20 such large investments in African countries alone, and notes an escalating trend. This month the South Korean firm Daewoo unveiled plans to lease one million acres of land (a land area the size of Belgium) in Madagascar, to meet Korean food needs. While loss of faith in markets may be triggering business to seek these deals, and deepening financial insecurity may trigger governments in Africa to make such deals, local farmers and communities are least consulted, and from the evidence of trends to date, are most likely to lose control over land, food and economic security.
So while powerful interests are oddly comfortable today talking about financial, energy, food, climate and other crises, there is silence on the crisis of injustice.
The increasing control of the world’s wealth by a diminishing number of players in the face of wide deprivation of the majority of people is a crisis of injustice. The pursuit of private wealth through appropriating collective natural, social and economic resources in a manner that undermines long term survival is a crisis of injustice. The failure of governments, nationally and globally, to meet basic human rights and needs when the resources are there is a crisis of injustice.
The quest for justice thus becomes a focus of ordinary people’s responses. There are many examples of this. In Zimbabwe this week, the Chitungwisa Residents and Rate Payers Association filed a lawsuit this month against the Zimbabwe National Water Authority for the lack of safe drinking water. While overshadowed by the scale of and necessary emergency responses to the cholera crisis, this action is nevertheless one by affected residents to call to account those in authority for how decisions are being made, how resources are being used and for whom power is being exercised. In this newsletter there is similar report of health activists calling leaders of high income countries to account: “For the developed country governments now to use their dominant position in our current system of global economic governance to deal with their own (largely self-inflicted) problems, while ignoring the much greater and longer-standing grievances of the developing world and the profound and urgent global challenges of ill-health, poverty and climate change, would be a betrayal”. As the legitimacy of current policies and institutions are being fundamentally challenged by the multiplicity of crises, more people are beginning to call it what it is- a crisis of injustice.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org.
1. Editorial
“We demand the inclusion of the Right to Health in the new Zimbabwe constitution!”
This was the slogan at the Community Working Group on Health 15th national conference. The conference was held in October 2008 in Harare and coincided with the organisation’s 10th anniversary celebrations.
The CWGH was born in early 1998, to lead and give visibility to community processes in health. Ten years later over ninety participants attended the conference, including CWGH national members, partners, activists, health cadres and Health Literacy facilitators from 21 of the 25 CWGH districts. The conference reviewed the path that the CWGH has walked through the past ten years. We noted that as much as the CWGH has over the years positioned itself as a voice in the health sector and built community power, still the health sector has continued to deteriorate. The current socio-economic and political environment has not only perpetuated the deterioration, but has also made it increasingly difficult for civil society to offer alternatives for health problems. It was thus noted that the network needed to not only strengthen the existing structures and processes in the network, but also to re-strategise on how best to use these to engage on and advance health under the prevailing harsh environment.
At the conference our health literacy facilitators from 21 districts reviewed the work they were doing to widen social awareness and action on health. Despite the political volatility, we heard from district after district that of actions being taken, including in engaging with the political leadership on health issues. The work of the facilitators has increased the involvement of communities in health actions within communities and around Primary Health care, whether within the community on environmental health, or mobilising resources to support health centres. These are being done through community level initiative with limited external support. It was clear to us that we need to strengthen the programme and these cadres, to cement the work we are doing at community level and translate information into action.
One of the clearest messages was to revive the Primary Health Centre (PHC) concept and comprehensive PHC , if there is hope for change in the health sector. Mary Sandasi, a CWGH national member pointed to the relevance of PHC even 30 years after the Alma Ata declaration to re-build the declining health sector, particularly as it puts the people at the centre of the health system. The CWGH will consistently engage with stakeholders and government to make PHC a more central policy principle, and we will strengthen community structures such as health centre committees and boards and committees at district and national level to organise public efforts to achieve this principle.
As the health sector deteriorates, the gap between rich and poor has continued to widen. Poor people struggle to access health, and higher income groups claim a larger share of public health sector resources. We see EQUINET’s ‘Reclaiming Resources for Health’ book as a resource to inform how we can address unfair, avoidable differences in health. For example, the CWGH has over the past decade taken up equity issues with the Parliamentary Portfolio Committee on Health (PPCH), the Ministry of Health and Child Welfare (MoHCW) and other stakeholders to push for resources to go to services that support poor communities. We have for many years raised attention to the need for more resources to go to disease prevention, for example, and continue to see this as an issue, to ensure that we have safe living environments and communities.
While we commemorated our tenth anniversary, it was difficult to call it a celebration given the collapse of our health care delivery system. What we did celebrate was the dedication and commitment that people have put into the organisation and the struggle for health in the past ten years. The CWGH has grown to be a prominent voice in health, has won the hearts of many to champion peoples health issues and has given greater profile to the positive force that people provide in dealing with health problems. We have grown from strength to strength, but so too have the challenges we face!
To back our efforts to address these, the CWGH membership unanimously endorsed that the network champion the right to health, and push its inclusion in the production of a new Zimbabwe constitution. Taking the theme for the year; ‘CWGH @ 10: In Pursuit of Equity in Health through People Centred Health Systems’ we see that embedding the right to health in our constitution will give us the bottom line we need to make it clear that everyone has a claim to health and health care, no matter what the economic, socio-political, race, creed, gender or other feature. It will be a right that we will fight to include, through social action, and that we will ensure is not left on paper, but protected and promoted, through social action.
Further information on Community Working Group on Health can be found at www.cwgh.org.zw. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org.
2. Latest Equinet Updates
This report provides an overview of the status of health care financing in seven East and Southern African (ESA) countries (Malawi, Namibia, South Africa, Tanzania, Uganda, Zambia, Zimbabwe). It draws on country case-studies and a collaborative cross-country analysis undertaken at an EQUINET workshop. Health care financing issues are considered through an equity lens, with a focus on revenue collection, pooling of funds and purchasing. There remains a heavy dependency on donor funding in several countries. While debt relief initiatives are translating into increased government funding for health care in some countries, in other countries, the health sector has not benefited much from reduced debt servicing. Due to high levels of out-of-pocket payments in many ESA countries and a heavy emphasis in the tax system on VAT, individual households carry a heavy burden. Health insurance is growing in popularity, particularly community-based health insurance which has placed the financing burden on relatively poor rural communities and those living in informal urban areas. All the countries under review have poor fund pooling with little in the way of risk equalisation mechanisms, which severely limits the potential for income and risk cross-subsidies. To achieve equitable health care financing it is necessary to: eliminate, or at least reduce out-of-pocket payments; increase the funding of health services from tax revenue; and introduce mechanisms to integrate all forms of pre-payment (i.e. tax funding and health insurance).
All abstracts for the EQUINET conference must be submitted on or before January 30 2009. The Third EQUINET Regional Conference on Equity in Health in east and southern Africa will be held at Speke Conference Centre, Munyonyo, Kampala, Uganda September 23rd -25th 2009. The conference theme is 'Reclaiming the Resources for Health: Building Universal People Centred Health Systems in East and Southern Africa'.
The themes are listed in the EQUINEt website. Sessions will be 2-3 hours in length and interactive in nature. Presenters may be asked to present verbally, using Power-oint, or using a visual presentation of a paper using charts, photos, drawings and/or text mounted on a poster board. The sessions will include brief summary presentations of the accepted abstracts on the theme and aim to give adequate time for full facilitated discussions of work and the issues raised. The Abstract submission form and registration form can be downloaded at the conference website.
Abstracts are a maximum of 400 words and typed at MS Word documents in Arial 11pt font. The title should be no more than 50 characters including punctuation, but long enough to identify the nature of the study. Ensure the abstract provides information on the findings. Accepted abstracts will appear in print in a bound abstract book distributed at the conference, and may also be posted on the conference web site.
Temos o conhecimento, habilidade, e experiência de superar desigualidades persistentes na saúde na Africa Oriental e Austral. Esta análise providencia uma mensagem inspiradora e emposada, explorando vários aspectos da saúde e sistemas da saúde e fornecendo muitos exemplos de boa prática na região. A evidência dentro desta análise aponta para três formas em quais reclamando os recursos para a saúde pode melhorar a equidade da saúde. Estas são: para as pessoas pobres reclamar uma divisão mais justa dos recursos nacionais a fim de melhorar a sua saúde; para um regresso mais justo para Africa Oriental e Austral da economia global a fim de aumentar os recursos para a saúde; e para uma divisão mais ampla dos recursos nacionais e globais para serem investidos nos sistemas redistribuitivos da saúde a fim de superar os efeitos empobrecidos da má-saúde. Embora a imagem de saúde da Africa Oriental e Austral está actualmente triste, com taxas altas de mortalidade, baixa esperança da vida e cargas altas de subalimentação, HIV e SIDA, tuberculose (TB) e malaria, a mensagem que emerge deste livro é uma de esperança e reconhecimento das nossas forças e possibilidades para acções.
This report presents the proceedings and debates at a meeting, held in Munyonyo Uganda September 16-18 2008, of parliamentary committees responsible for health from twelve countries in East and Southern Africa, with technical, government and civil society and regional partners. The meeting reviewed the health equity situation in the region in relation to regional goals (e.g. Maputo Plan of Action, Abuja Declaration) as well as international frameworks (e.g. ICPD PoA, and the MDGs). Various areas of parliamentary work were reviewed in relationto health equity and primary health care: from a budget and policy oversight lens, the meeting reviewed AIDS and sexual and reproductive health policies and commodity security, and the laws and budgets for this. The meeting explored options for fair and adequate health care financing and for promoting equitable resource allocation, particularly in relation to budget processes. The legal rolesof parliament were discussed in relation to the application of international and regional treaties and conventions on the right to health; and the measures to promote health in patenting laws and the EPA negotiations and more generally in trade agreements. the meeting also explored developments in primary health care and social empowerment in health. The report presents the resolutions of the meeting and and the proposals made to strengthen SEAPACOH regional networking and organisation.
Os diferentes distritos, regiões e províncias num país têm diferentes necessidades de saúde e recursos disponíveis dos cuidados da saúde. Os fundos do governo justamentamente distribuídos para a saúde assim chamam para uma formula que calcula a divisão dos recursos totais para seremalocados para áreas baseadas sobre indicadores da necessidade relativa para cuidados da saúde naquela área. Muitos países na região usam tais formulários. Eles usam diferentes indicadores da necessidade de saúde, incluindo a capacidade populacional e a sua composição, os níveis da pobreza, doenças específicas e mortalidade. Revelando experiência em certos países selecionadodentro da região, esta breve política sugere que os países podem fortalecer uma alocação equitativa dos recursos para a saúde através de aumentar a cota global do financiamento do governo alocada ao sector da saúde, trazendo ajuda externa e o financiamento do governo num só conjunto de fundose aloca-los atraves dum mecanismo simples. Alocação de recursos equitativos chama para os governos estabelecer alvos anuais para alocação equitativa destes fundos públicos, e colecionainformação para monitorar e reportar sobre progresso em alcançar estes alvos, incluindo parliamentos e sociedade civil. Alocação de recursos é um processo politizado e requer umcuidadosa, incluindo, planificar, oraganizar e providencia de incentivos para a re-distribuição do pessoal de cuidados da saúde para áreas onde a necessidade da saúde é alta.
No ano 2001, em Abuja na Nigeria, os Chefes dos estados membros da União Africana comprometeram para alocar ao menos 15% de orçamentos dos governos para seus sectores da saúde. Ao mesmo tempo chamaram os países doadores para complementar seus esforços a fim de mobilizar domesticamente os recursos através de cumprirem o seu compromisso de dedicar 0.7% do seu PBN como AOD para os países em via de desenvolvimento e cancelar a dívida externa da Afica em favor Do aumento de investimento no sector social. O alvo de Abuja, assim, consiste de três componentes; os países Africanos deveriam: mobilizar os recursos domésticos para a saúde (15% agora); estar não sobre-carregado pela prestação de contas do débito (Cancelamento de Débito agora); e ser apoiada pela AOD (0.7% PBN agora).
This workshop brought 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 updated 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. Delegates reviewed a technical analysis report on the services negotiations in the Economic Partnership Agreements and developed positions to be advanced for the protection of public health in trade agreements and specifically negotiating positions on the services negotiations.
3. Equity in Health
In this paper, the author argues that, contrary to popular belief, numerous Poverty Reduction Strategy Papers (PRSPs) and aid programmes do not adequately address the MDGs. The paper analyses the substance of 22 developing countries’ PRSPs and the policy frameworks of 21 bilateral programmes. Major findings of the analysis include noting that economic growth for income poverty reduction and social sector investments (education, health and water) are important priorities in most of the PRSPs, yet decent work, hunger and nutrition, the environment and access to technology tend to be neglected. PRSPs also emphasise governance as an important means of achieving the MDGs, but they focus mostly on economic governance rather than on democratic (participatory and equitable) processes.
This report investigates the cause of a 24% drop in mortality in children under 5 years in Tanzania between 2000 and 2004. It investigated contextual factors that could have affected child mortality, in order to understand the likelihood of meeting the Millennium Development Goal for child survival (MDG 4). The observed reduction coincided with important improvements in Tanzania's health system, including a doubling of public expenditure on health, decentralisation and sector-wide basket funding, and increased coverage of key child-survival interventions, such as integrated management of childhood illness, insecticide-treated nets, vitamin A supplementation, immunisation and exclusive breastfeeding. The authors conclude that Tanzania could attain MDG 4 if this trend in improved child survival were to be sustained through increased investment.
In this open letter, participants of the Conference on the Social Determinants of Health have called on the British Prime Minister to ensure that consideration at the forthcoming G20 meeting onthe financial crisis is not limited to the immediate problems of the banking and financial system. Leaders should extend their review to the key global challenges of ill-health, poverty and climate change, and the anachronistic and undemocratic structure of global governance which underlies the failure of the global community to deal with these issues effectively. The letter calls for reform of the ‘Bretton Woods’ institutions to be fully inclusive of all countries, on an equal basis, and for the institurtions to reflect contemporary standards of democracy, transparency and accountability. It is only through such a system of global governance, placing fairness in health at the heart of the development agenda and genuine equality of influence at the heart of its decision-making, that coherent attention to global health equity is possible.
In her speech, World Health Organization General Secretar Dr Margaret Chan referred to the current global economic crisis and its consequences for the health sector. The health sector had no say when the policies responsible for these crises were made, yet it bears the brunt. The remarks point to the high level of preventable disease and lack of access to health care services, and to massive inequalities in resources for health. For 5.6 billion people in low- and middle-income countries, more than half of all health care expenditure is through out-of-pocket payments. With the costs of health care rising and systems for financial protection in disarray, personal expenditures on health now push more than 100 million people below the poverty line each year. Last week, WHO issued its annual World Health Report which documents a number of failures and shortcomings that have left the health status of different populations, both within and between countries, dangerously out of balance. The WHO Commission on Social Determinants of Health report challenges governments to make equity an explicit policy objective in all government sectors. "Equity in access to health care comes to the fore as a way of holding globalization accountable, of channelling globalization in ways that ensure a more fair distribution of benefits, a more balanced and healthy world".
4. Values, Policies and Rights
A resolution calling on the African Commission on Human and Peoples’ Rights to recognise human rights to access needed medicines was passed at a meeting of African human rights organisations in Abuja, Nigeria. The NGO forum was composed of about 100 human rights organisations in Africa with observer status before the African Commission. The resolution calls on the Commission to recognise access to needed medicines as a fundamental component of the right to health and clarify the state obligations in this regard. It specifically calls on the Commission to fulfil its duty to respect, protect and enforce rights to access to medicines. This includes taking full advantage of all flexibilities in the WTO Agreement on Trade-related Aspects of Intellectual Property (TRIPS) that promote access to affordable medicines.
In the past six years the UN Special Rapporteur on Human Rights and the Human Rights Centre have prepared an impressive body of reports offering detailed analyses on elements of the right to health. They have developed a framework for analysis of health-related issues that had so far not been studied from a human rights perspective. A September 2008 symposium reviewed these themes and strategies and made suggestions for further research and implementation. The meeting covered health systems and the right to the highest attainable standard of health, mainstreaming a human rights-based approach to health and the Special Rapporteur’s missions and reports, such as those on community participation and HIV and AIDS.
5. Health equity in economic and trade policies
Doha is known for having its name attached to the World Trade Organisation (WTO) Doha Development Round, the current trade-negotiation round of the World Trade Organisation which commenced in November 2001. As of 2008, talks have stalled over a divide on major issues, such as agriculture, industrial tariffs and non-tariff barriers, services, and trade remedies. Major negotiations are not expected to resume until 2009. Civil society organisations have pointed out a need for a strong regulatory framework to counter well-documented abuses, and ensure positive developmental impacts of foreign direct investment. They recommended specific mechanisms, such as country-by-country reporting to regulate transnational corporations, policies to harness the revenue from natural resource extraction and commitment to combat increasing trade and investment liberalisation.
With many countries repaying their loans to the International Monetary Fund (IMF) and not seeking new lines of credit, the institution’s traditional means of generating income is dwindling. Facing a budget shortfall of US$400 million in 2010, in April, the IMF’s Executive Board approved a proposal to sell some of its gold reserves. The revenue will be used to create an endowment whose earnings will assist in financing the institution’s administrative budget. Civil society is writing to urge that before the Executive Board implements gold sales, it must insist on meaningful pro-development reforms in IMF policy in developing countries and attach conditions to how gold sales will occur. Over the last three decades, IMF policies have limited development, and denied opportunity and decent livelihoods to hundreds of millions of people.
The World Health Organization has released a long-awaited list of high-level experts tasked with finding innovative funding mechanisms for needed medical research on neglected diseases. The list largely contains governmental and intergovernmental representatives, and first reactions to it have been generally positive. The creation of this ‘results-oriented and time-limited’ expert group was a key outcome of the WHO’s global strategy and plan of action on public health, innovation and intellectual property, approved at World Health Assembly in May. The 24-member body will look at the current financing and coordination of research and development, as well as proposals for new and innovative sources of funding to stimulate research and development in diseases which disproportionately effect developing countries.
6. Poverty and health
Citizens have demanded that world leaders keep promises to achieve the Millennium Development Goals and end inequality. More than 116 million people – nearly 2% of the world’s population – mobilised at events in 131 countries on 17–19 October as part of the Stand Up and Take Action campaign. The mobilisation, which was ratified by the Guinness Book of Records as breaking the world record for the biggest mass mobilisation on a single issue, sends a clear message to world leaders that citizens want promises to end poverty to be fulfilled. At least five million additional people – many in Africa and Latin America – participated at events not submitted before the Guinness deadline. The United Nations Millennium Campaign has vowed not to stop mobilising and advocating for action until the Millennium Development Goals are achieved for the poorest people in the world.
7. Equitable health services
The use of insecticide-treated bed nets (ITNs) to protect children from malaria has risen six-fold in the past seven years, but 90 million children still do not have access to this simple protective tool, and remain at risk from the life-threatening disease. When African heads of state met in 2000, the Abuja Declaration stated that they would work towards protecting 60% of their vulnerable populations with insecticide treated nets. This study examines what has been achieved since. Data from 40 African countries which shows that at the time of the Abuja meeting in 2000 just over 3% of Africa’s young children were protected by a treated mosquito net. Seven years later this increased to only 18.5%. The authors report that bed net use increases faster in countries that distribute them free of charge by an average of 25% compared to 4% when people have to pay for them.
Zimbabwe's cholera epidemic has crossed into South Africa, with four confirmed diagnoses in a total of 68 suspected cases in the border town of Musina, according to aid workers as of 19 November 2008. The cholera epidemic in Zimbabwe has flared up in several parts of the country, including the capital, Harare, and its satellite town of Chitungwiza, as a result of the collapse of water and sewerage services, worsened by uncollected refuse and the start of the rainy season. Humanitarian officials have reported that a total of 2,893 people were infected by the waterborne disease between the beginning of August and mid-November, with at least 115 deaths. The UN children's agency, UNICEF, and the World Health Organisation (WHO) have also been assisting in the provision of drinking water.
The objective of this study was to evaluate the impact of rapid diagnostic tests (RDTs) on prescribing behaviours, assess prescribers' and patients' perceptions, and identify operational issues during implementation. Baseline data was collected at six Tanzanian public dispensaries. RDTs were implemented for eight weeks and data collected on frequency of RDT use, results, malaria diagnoses and the prescription of antimalarials. The study found that overprescriptions decreased over the study period. There was a high degree of patient/caregiver and provider acceptance and satisfaction with RDTs. Implementation should include community education, sufficient levels of training and supervision and consideration of the need for additional staff.
Health workers of Parirenyatwa and Harare Central Hospital have issued a petition for urgent action to address the prevailing crisis in Zimbabwe’s public health system. Problems within public health institutions include a serious lack of medical supplies, functional equipment and drugs. Since all hospitals and clinics are closed, Zimbabweans that fall ill have no access to health care, given the high cost of private health care. Problems facing health workers include poor salaries (which should be paid in foreign currency, not Zim dollars), rising transport costs and bad working conditions. The continued failure to address the above issues has resulted in lack of services in public health institutions and health workers failing to come to work. The workers call upon the responsible authorities to take urgent steps to remedy the situation above in consultation with the health workers concerned.
Access to improved sanitation is a matter of human rights, says the UN. There is compelling evidence that sanitation brings the single greatest return on investment of any development intervention (roughly $9 for every $1 spent). Yet it remains the most neglected and most off-track of the Millennium Development Goal (MDG) targets. Sanitation has been considered as the most important medical advance since 1840 – beating antibiotics, vaccines and anaesthesia. Access to sanitation is essential for people to live in dignity, yet 40% of the world still does not have basic sanitation. The scale of the crisis is enormous, according to the United Nations, which reports that 2.5 billion people do not have access to proper sanitation.
The CWGH made a number of resolutions after the 15th National Conference in Harare, including a demand that the right to health be included in the National Constitution. It committed itself to strengthening primary health care and district systems by lobbying for incentives and resources for community health workers from government, getting health institutions to remove high charge barriers and lobbying government for policies to retain health workers. It will also lobby the government to provide free access to safe water as a human right, as well as lobby the Parliamentary Portfolio Committee on health for increased health funding and government for the fair allocation of resources at national level. Community participation should also be promoted. That CWGH will develop a proactive agenda on health issues and forge and strengthen strategic partnership locally and regionally to take this forward, capacitate its districts to enable them to advance and monitor the implementation of these resolutions and ensure that the health delivery system is not used for partisan politics.
Zimbabwe’s overall health service has been steadily declining for the last five years. The Zimbabwean health service today is wracked by critical shortages of essential drugs and skilled and experienced personnel. Another challenge is there has been no comprehensive assessment of Zimbabwe’s health system since 2006, making it difficult to assess its true state. Also, its disease surveillance and early warning system, which depends on a weekly epidemiological system, has been compromised in terms of timeliness and completeness of data, which is only around 30%. Universal access to basic health services is compromised due to deteriorating infrastructure, staffing and financial resources. Reactivating primary health care services should keep being addressed as a matter of emergency. Zimbabwean health facilities face a massive gap – estimated this year at 70% – in required medicines due to reduced local manufacturing capacity, which has been weakened by a lack of foreign currency. This is despite support received from different partners through UNICEF’s procurement systems. A large cholera outbreak is affecting most regions of the country, with more than 11 700 cases and 473 deaths recorded between August and 30 November. This represents a case fatality rate (CFR) of 4.0% nationally, but reached 50% in some areas during the early stages of the outbreak. The CFR benchmark should be below 1%. Cholera outbreaks in Zimbabwe have occurred annually since 1998, but previous epidemics never reached today’s proportions. The last large outbreak was in 1992 with 3000 cases recorded. Cholera cases have also been reported either side of Zimbabwe’s border with South Africa, Botswana and Mozambique, demonstrating the subregional extent of the outbreak.
8. Human Resources
Global Policy Advisory Council members have reviewed and responded to the WHO Draft Code of Practice and had a number of recommendations to make. They believe the Code needs to reflect further on World Health Assembly Resolutions 57.19 and 58.17 and to focus more strongly on mitigating the adverse effects of health personnel migration and its negative impact on health systems in developing countries. A strong preamble is needed to appropriately inform the rationale, context and vision underlying the accompanying articles. The current Code pays much attention to the role of member states generally, but the specific roles of source and destination countries, health workers, recruiters/ employers and other relevant stakeholders require further elaboration. There was wide, though not unanimous, agreement that the principle of shared responsibility is paramount: states that are global employers must help support their source countries’ local health workforce. Clear implementation guidelines are lacking, specifically about how and what information must be collected. Developing countries will need technical and capacity-related assistance, otherwise they will not be able to pay the costs of implementing the Code.
This article profiles three leaders who have made a significance difference in the HR situation in their countries. By taking a comprehensive approach and working in partnership with stakeholders, these leaders demonstrate that strengthening health workforce planning, management, and training can have a positive effect on the performance of the health sector. Three profiles are presented, from Afghanistan, South Africa and southern Sudan, revealing common approaches and leadership traits while demonstrating the specificity of local contexts. In the South African profile, Dr. Mahlathi, Deputy Director General of Human Resources for South Africa's national Department of Health (DOH) is discussed. South Africa will need a multisectoral approach, with strong health management and leadership and additional human and financial resources to help meet the needs of its citizens.
9. Public-Private Mix
On paper, South Africa has some of the world's best HIV workplace programmes, but on the ground they just aren't adding up. Diamond mining giant De Beers has long boasted that 86% of employees at its six mines have been tested by its voluntary counselling and testing (VCT) programme. The company estimates that 10% of its workforce is HIV-positive, but markedly fewer access the antiretroviral (ARV) treatment programme. Workers' fears about confidentiality, a preference for traditional medicine and poor patient-doctor communication were all cited as challenges to raising treatment numbers, according to an ongoing study by De Beers. The research was presented by the company and the University of KwaZulu-Natal (UKZN) on 6 November at the Private Sector Conference on HIV and AIDS, hosted by the South African Business Coalition on HIV and AIDS (SABCOHA).
This article reviews Klarman’s classic article ‘The case for public intervention in financing health and medical services’. Government intervention still plays an essential role in most public health actions but the links between public health expenditure and health improvement are tenuous and econometric analyses have yielded widely divergent results, leading us to the highly consensual formula that ‘it is not enough merely to increase expenditure on health’. Contemporary analyses agree that efforts to strengthen health systems or to control neglected diseases are underfunded. Increased expenditure on health will be a source of employment for the surplus workforce of the manufacturing sector and the health industry will be the driving force of tomorrow’s economy.
10. Resource allocation and health financing
The aim of this analysis is to explore the extent of fragmentation (when a large number of separate funding mechanisms result in health inequities) and its effect on universal coverage in the health systems of three African countries: Ghana, South Africa and Tanzania. It draws on the results of the first phase of a three-year project analysing equity in the finance and delivery of health care in Ghana, South Africa and United Republic of Tanzania. The analysis presented indicates that South Africa has made the least progress in addressing fragmentation. It recommends that, to achieve universal coverage, the size of risk pools must be maximised, resource allocation mechanisms must be put in place and as much integration of financing mechanisms as possible must be done to promote universal cover with strong income and risk cross-subsidies in the overall health system.
In the debate surrounding aid effectiveness in Africa, some have suggested that these countries ought to ‘wean themselves off’ aid dependency. This paper provides five strategies that African countries can employ to eliminate the need for donor funding for health. First, they can reduce economic inefficiencies. Second, they should institutionalise economic efficiency monitoring within national health management information systems with a view to implementing appropriate policy interventions to reduce wastage of scarce health systems inputs. Third, they can reprioritise public expenditures by, for example, cutting back on military spending and raising additional tax revenues by increasing the tax share to at least 15% of gross domestic product (GDP). Fourth, more private sector involvement in health development is required and, last, the fight against corruption needs to be stepped up.
This paper explores the factors associated with household coping behaviours in the face of health expenditures and provides evidence for policy-makers in designing financial health-protection mechanisms. Data from the 2002–2003 World Health Survey was analysed. The paper found that many patients finance their health care by borrowing and selling assets, ranging from 23% of households in Zambia to 68% in Burkina Faso. High-income groups were less likely to borrow and sell assets, but coping mechanisms did not differ strongly among low-income quintiles. Households with higher inpatient expenses were significantly more likely to borrow or sell than those financing outpatient care or routine medical expenses, except in Burkina Faso, Namibia and Swaziland. In eight countries, the coefficient on the highest quintile of inpatient spending had a p-value below 0.01. In conclusion, the health financing systems of most African countries are too weak to protect households from health ‘shocks’, like unexpected health costs that require them to borrow or sell their assets. Formal prepayment schemes could benefit many households, and an overall social protection network could help to mitigate the long-term effects of ill health on household well-being and support poverty reduction.
Basing drug reimbursement on cost-effectiveness provides too little incentives for research and development. The reason for this is that cost-effectiveness is concerned with immediate value for money. But since the price of a drug usually declines over time, the drug might well provide value for money as seen over its entire life cycle, even though its price during patent protection is too high to warrant reimbursement according to the cost-effectiveness decision rule. This paper shows in a theoretical model that welfare could be improved if decision-makers took a longer perspective and initially allowed higher prices than immediate value for money can motivate. It also discusses the real-world relevance of applying dynamic cost-effectiveness.
High levels of out-of-pocket payments have limited the ability of people to use services in poor countries. Evidence shows that removing or reducing user fees increases utilisation, at least in the short term, while out-of-pocket payments are often made by borrowing or by selling assets, putting people into debt and restricting their long-term economic survival. An important challenge therefore is to shift away from out-of-pocket payments through the development of prepayment schemes for universal coverage but, in resource-poor settings, additional funds will be critical. Some researchers claim that it is possible for developing countries to ‘wean themselves off’ international donor funding, essentially through the better use and management of domestic resources, but others believe it’s impossible for them to finance universal access without donor funding.
This report published by Oxfam examines the role of health insurance mechanisms will close health financing gaps and benefit poor people. The mechanisms discussed in this paper are private health insurance, private for-profit micro health insurance, community-based health insurance and social health insurance. It describes those mechanisms and their success or failure to deliver health rights particularly for people living in poverty.
This paper tackles the paper by Kirigia and Diarra-Nama from the WHO Regional Office for Africa, which claims that countries in the WHO Africa Region need to ‘wean themselves off’ donor funding for health in order to meet the annual WHO target of US$40 per person required to provide universal coverage. The paper evaluated the five strategies that the Kirigia and Diarra-Nama paper proposed and dismissed all of them. It predicted their impact on eight countries and noted a reduction in military expenditure would not make a difference either, as expenditure in these countries is low. Six countries still face a huge gap between current total health expenditure and the revised target made by the Commission on Macroeconomics and Health and need more aid urgently. They can be helped through sustained international health aid, with health recognised as a human right.
This response to Kirigia and Diarra-Nama’s paper points out that they do not propose alternative strategies to enable African countries to mobilise the funds without depending solely on donor funding. Kirigia and Diarra-Nama argue that eight countries whose current military spending is above the regional average of US$ 16 per person may have scope for savings. Thirteen countries whose tax share of GDP is less than 15% have scope for raising additional revenue by improving efficiency of their tax administration systems. The amounts, however small, are not insignificant in these countries where more than 60% of the population live below the international poverty line of US$1 per person per day. The effectiveness of international aid should also be judged on the extent to which it helps recipient countries to ‘wean themselves off’ external donor funding.
There is no good reason why a country with an income of US$366 per capita cannot afford to increase its domestic health spending from US$20 to US$34. It is the value of forgone alternative benefits (as perceived through either collective decision making or unilateral decisions of political authority) that puts a limit on how much a society can spend on health, not some health expenditure-GDP ratio technical limit. Further, general lessons of experience from parts of east and south-east Asia and Latin America show that, as countries experience substantial broad-based economic and social progress, greater health funding becomes feasible. Such a situation requires time, but has been realised in these countries within about 20 to 40 years. The author believes it will take a long time to reduce the high dependency on donor aid, but Africa should aim to increase domestic resource mobilisation.
In 2005, the member states of WHO adopted a resolution to develop health financing systems to deliver universal coverage of health services by moving away from out-of-pocket payments and developing prepayment methods instead. This paper proposes a comprehensive framework, focusing on health financing rules and organisations, that countries can use to achieve universal coverage. For many countries, it will obviously take some years to achieve the goal and their responses will be determined partly by their own histories and the way their health financing systems have developed to date, as well as by social preferences relating to concepts of solidarity. The proposed framework considers fund collection, pooling and purchasing/provision separately, as well as the links between the three functions to indicate what rules need to be modified or developed and where organisational capacity should be strengthened.
11. Equity and HIV/AIDS
This report presents data on anti-retroviral therapy (ART) in both the public and private sectors in Malawi. By the end of June 2008, there were 207 health facilities in Malawi in the public and private health sector delivering ART to HIV-positive eligible patients. In the second quarter of 2008 (April to June), there were 19,849 new patients registered on ART. Cumulative treatment outcomes by end of June were: 66% alive and on ART at the site of registration, 11% dead, 11% lost to follow-up, 12% transferred out to another facility (and were presumably alive) and <1% stopped treatment. By the end of June 2008, there were 32 sites with over 1,000 patients alive and on treatment and 10 sites with over 2,000 patients alive and on treatment. Of the 10 sites with more than 2,000 patients, four did not have an electronic data system in place.
South Africa recently launched a national antiretroviral treatment programme. This has created an urgent need for nurse-training in antiretroviral treatment (ART) delivery. The PALSA PLUS programme provides guidelines and training for primary health care (PHC) nurses in the management of adult lung diseases and HIV/AIDS, including ART. A process evaluation was undertaken to document the training, explore perceptions regarding the value of the training. It found that nurse uptake of PALSA PLUS training was high. Ongoing on-site training of PHC nurses enhanced their experience of support for their work by allowing not only for ongoing experiential learning, supervision and emotional support, but also for the ongoing managerial review of all those infrastructural and system-level changes required to facilitate health provider behaviour change and guideline implementation.
This paper looks at anecdotal evidence that unproven AIDS 'cures' are widely used, and promoted by some countries' governments, instead of evidence based antiretroviral therapy (ART). Ot focuses on reasons why these 'cures' are used, including the high cost of conventional medicine and stigma associated with accessing healthcare systems. The authors discuss case studies from Gambia, South Africa and Iran where governments have promoted unproven treatment creating confusion over the legitimacy of AIDS medicines. Governments appear reluctant to dismiss these 'cures' for fear of being seen to criticise traditional medicine. The authors conclude that the full extent of the availability and use of unproven 'cures' and counterfeit antiretrovirals (ARVs) has not been fully documented, and that more research, as well as scaling up of ARV programmes, is needed.
Data from sentinel surveillance at antenatal clinics and a national population survey were used to estimate the trend of adult HIV prevalence from 1980 to 2007 in Botswana. Prevalence has declined slowly in urban areas since 2000 and has remained stable in rural areas. The number of new adult infections has been stable for several years and number of new child infections has declined due to coverage of ART that reaches over 80% in need and nearly complete coverage of an effective program to prevent mother-to-child transmission (PMTCT). The need for ART will increase by 60% by 2016. Botswana's PMTCT and treatment programs have achieved significant results in preventing new child infections and deaths among adults and children. The number of new adult infections continues at a high level. More effective prevention efforts are urgently needed.
The South African government’s health department controversially declined to accept freely donated nevirapine and grants from the Global Fund, despite the fact that it is one of the countries most severely affected by HIV and AIDS, because they claimed antiretroviral (ARV) drugs were not useful for patients. This study aimed to assess the department’s assertion. Using modeling, it compared the number of persons who received ARVs for treatment and prevention of mother-to-child HIV transmission between 2000 and 2005 with an alternative of what was reasonably feasible in the country during that period. It calculated that more than 330,000 lives were lost because a feasible and timely ARV treatment programme was not implemented in South Africa. Thirty-five thousand babies were born with HIV, resulting in 1.6 million person-years lost by not implementing a mother-to-child transmission prophylaxis programme using nevirapine. The total lost benefits of ARVs are at least 3.8 million person-years for the period 2000–2005.
This study assessed the effect of adherence to HAART on survival in The AIDS Support Organization (TASO) community HAART programme in Kampala, Uganda. It took the form of a retrospective cohort of 897 patients who initiated HAART at TASO clinic, Kampala, between May 2004 and December 2006. A total of 7,856 adherence assessments were performed on the data. The study study showed that good adherence and improved survival are feasible in community HIV/AIDS programmes such as that of TASO, Uganda. However, there is need to support community HAART programmes to overcome the challenges of funding to provide sustainable drug supplies, the provision of high quality clinical and laboratory support and achieving a balance between expansion and quality of services. Measures for the early identification and treatment of HIV infected people should be strengthened.
AIDS activists in Uganda have criticised a proposed new law that will force HIV-positive people to reveal their status to their sexual partners, and also allow medical personnel to reveal someone's status to their partner. The HIV Prevention and Control Bill (2008) is intended to provide a legal framework for the national response to HIV, as well as protect the rights of individuals affected by HIV. While activists agree that Uganda needs legislation to guide its HIV policy, they are concerned that the bill in its current form could worsen the difficulties many HIV-positive people experience, such as stigmatisation.
12. Governance and participation in health
Health experts and activists have heavily criticised African governments for failing to collaborate with civil society organisations (CSOs) on health research and health policy development. Governments tend to perceive CSOs as a threat because they are independent, often critical of government and see their role as holding politicians accountable, health activists said during the World Health Organisation (WHO) Global Ministerial Forum for Health Research in Bamako, Mali. As a result, many governments ignore calls for public participation. Without inclusion of CSOs, African governments' efforts to create sustainable health systems would fail. With increased partnerships between researchers, governments and CSOs, the health agenda could be taken forward more efficiently and in a more equitable way.
This article discusses the exemplary leadership women have displayed in organisations they lead in Tanzania, such as women-led organisations like the Tanzania Gender Networking Programme (TGNP), Tanzania Women Lawyers Association (TAWLA), Women in Legal Aid Committee (WILAC), Legal and Human Rights Centre (LHRC), Medical Women Association of Tanzania (MEWATA), Equal Opportunities Trust Fund (EOTF), Wanawake na Maendeleo (WAMA) and the Tanzania Media Women Association (TAMWA). All these organisations have well-established constitutions-legally-binding documents that guide their operations, permanent premises, dynamic organisational structures and transparency in their operations as well as clean certificates of books of accounts. The organisations’ activities are generally recognised by the government, general public and the international community.
13. Monitoring equity and research policy
Diseases such as malaria and HIV that disproportionately affect the developing world cause immense suffering and ill health. Medical innovation has the potential to deliver new medicines, vaccines, and diagnostics to overcome these diseases, yet few treatments have emerged. Current efforts to resolve the crisis are inadequate: financing for research and development (R&D) is insufficient, uncoordinated, and mostly tied to the system of intellectual property rights. Delivering appropriate medicines and vaccines requires reforms to the existing R&D system and a willingness to invest in promising new approaches. Ultimately, it is a combined responsibility of all countries to find ways to ensure global R&D is organized to improve human health; inability to pay should not disenfranchise a large majority of the world’s population from access to effective healthcare.
Ministers of health, science and technology, and social development have met with scientific researchers and representatives from foundations, the private sector and civil society at the Global Ministerial Forum on Research For Health, held in Bamako, Mali from 17–19 November, an event unique in bringing together high-level leadership in sectors of health research that do not always have the chance to interact. They discussed the future of research for health on diseases disproportionately affecting the developing world. The focus was on collecting and sharing accurate data to demonstrate the demography of disease and to measure the impact of programmes. With sound data, it is possible to convince people, for example, that malaria is a huge problem, and it is a problem which affects some parts of the globe more than others. The final call to action and communiqué are expected to be released shortly at bamako2008.org.
14. Useful Resources
This guide argues that it is both necessary and feasible to remove user fees in order to help poorer people access basic healthcare. It also looks in detail at the case of Uganda, which removed user fees (discontinuing the policy of cost-sharing) in 2001. Using data from a range of countries and worked examples, it demonstrates how to estimate the effect of removing fees on utilisation and the resulting resource requirements. It describes five steps to follow to successfully remove user fees and maximise utilisation of health services: Analyse your starting position, estimate how removing fees will affect service utilisation, estimate additional requirements for human resources and drugs, mobilise additional funding, communicate the policy change and carefully manage the communication process.
Locally based Kenyan professionals and those in the Diaspora will now have the opportunity to exchange ideas and share knowledge following the launch of a Kenyan internet-based resource centre, the Kenya Knowledge Network (KNET). KNET will be an e-forum for debating major policy issues, where qualified subject matter specialists in the key areas of the Kenyan economy and its development management challenges can meet. The aim is to enable KNET to harness knowledge for development by establishing a community of practice, consisting of policy and research centres, professionals, policy makers and practitioners, and academics, who will participate in the formulation and management of development policies and programmes in Kenya. The website is not accessible to users just yet.
15. Jobs and Announcements
The Lancet, together with the Geneva-based Global Forum for Health Research, has announced the winners of the 2008 essay competition, Young Voices in Research for Health. The theme of this year’s contest was research for climate change and health. Essayists were asked to devise research questions on the topic as it applies to vulnerable populations around the world. Almost 300 entries were submitted, from 66 countries. A shortlist of 42 was chosen by a team of judges from the Global Forum and The Lancet. Six winners were selected from the shortlist: Enrique Falceto de Barros (Brazil), Philippa Bird (UK), Lester Sam Geroy (Philippines), Rhona Mijumbi (Uganda), Marame Ndour (Senegal), and Charles Salmen (USA).
This award celebrates the work of an individual, organisation or initiative that has shown outstanding vision and impact in improving healthcare in the developing world. Only work that has been completed or published after 1 January 2007, may be entered. You are able to enter in more than one category. The closing date for entries is 12pm, Friday 19 December 2008. The expert panel of judges will be looking for the individual, organisation or initiative that has most demonstrated. To enter the Global Leadership award, you will need to complete an entry form at the above website.
Significant human and financial resources have been invested worldwide in the collection of population, facility and community-based data. However, this information is often not used by key stakeholders to effectively inform policy and programmatic decision-making. As a result, many health systems fail to fully link evidence to decisions and suffer from a decreased ability to respond to priority needs at all levels of the health system. In an effort to strengthen the links between data and decision making, MEASURE Evaluation, the Health Metrics Network, and the East, Central and Southern African Health Community (ECSA) are co-organizing a meeting January 28-29, 2009 in Arusha, Tanzania with the objectives of sharing successful experiences in using health data to improve programs and policies. Proven approaches for improving the use of data, common challenges to data use and key priorities for creating a culture of evidence-based decision making will be shared in this two day, interactive meeting. The meeting will include plenary presentation, group discussion and break-out learning sessions. In addition to the symposium, a skills building session in approaches and tools to facilitate data use will be held on January 30.
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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